Provider Demographics
NPI:1417077330
Name:DAVIS, ROY CLARENCE
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:CLARENCE
Last Name:DAVIS
Suffix:
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 1:8080 WARD PKWY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-2034
Mailing Address - Country:US
Mailing Address - Phone:816-444-7688
Mailing Address - Fax:816-444-0290
Practice Address - Street 1:8080 WARD PKWY
Practice Address - Street 2:SUITE 140
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-2034
Practice Address - Country:US
Practice Address - Phone:816-444-7688
Practice Address - Fax:816-444-0290
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00978103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0004409354OtherAETNA
MO060265OtherVALUEOPTIONS
MO09686025OtherBLUECROSSBLUESHIELD
MO09686025OtherBLUECROSSBLUESHIELD