Provider Demographics
NPI:1124384359
Name:DAVIS, KENNETH WAYNE (SAC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:W
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SAC
Mailing Address - Street 1:1002 SE C ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-6327
Mailing Address - Country:US
Mailing Address - Phone:479-271-2120
Mailing Address - Fax:479-271-2219
Practice Address - Street 1:1002 SE C ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6327
Practice Address - Country:US
Practice Address - Phone:479-271-2120
Practice Address - Fax:479-271-2219
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15651131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)