Provider Demographics
NPI:1396217790
Name:DAVIS, KYLIE LOUISE (LICSW)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:LOUISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2443 MAMIE AVE E
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5906
Mailing Address - Country:US
Mailing Address - Phone:651-246-1033
Mailing Address - Fax:
Practice Address - Street 1:2443 MAMIE AVE E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55119-5906
Practice Address - Country:US
Practice Address - Phone:651-246-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-23
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health