Provider Demographics
NPI:1366468126
Name:DAVIS, CARL D JR
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:D
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 STATION AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-6778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:MO
Practice Address - Zip Code:65360-1449
Practice Address - Country:US
Practice Address - Phone:660-647-9921
Practice Address - Fax:660-647-3617
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002030477103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498319300Medicaid
MOR64C294Medicare ID - Type Unspecified
MOP74C294Medicare UPIN