Provider Demographics
NPI:1407213705
Name:DAVIS, SAMUEL KYLE (LPC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KYLE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6290
Mailing Address - Country:US
Mailing Address - Phone:970-433-5728
Mailing Address - Fax:
Practice Address - Street 1:2470 PATTERSON RD STE 6OFFICE5
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1028
Practice Address - Country:US
Practice Address - Phone:970-433-5728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COLPC.0015775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health