Provider Demographics
NPI:1508115601
Name:DAVISON, KENNETH RAY (LMHC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RAY
Last Name:DAVISON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CHILDREN'S WAY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:FL
Mailing Address - Zip Code:32832-8135
Mailing Address - Country:US
Mailing Address - Phone:286-668-4774
Mailing Address - Fax:386-668-0542
Practice Address - Street 1:51 CHILDREN'S WAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:FL
Practice Address - Zip Code:32832-8135
Practice Address - Country:US
Practice Address - Phone:286-668-4774
Practice Address - Fax:386-668-0542
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8051101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health