Provider Demographics
NPI:1316413818
Name:DAVIS, STACEY DAWN (LPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DAWN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11644 S WINCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7111
Mailing Address - Country:US
Mailing Address - Phone:913-424-4823
Mailing Address - Fax:
Practice Address - Street 1:9233 WARD PKWY STE 125
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-3340
Practice Address - Country:US
Practice Address - Phone:816-561-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001007479101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional