Provider Demographics
NPI:1518740380
Name:DAVIS, KENDALL OLIVIA
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:OLIVIA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 HYDE BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-2565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1304 HYDE BLVD
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2565
Practice Address - Country:US
Practice Address - Phone:908-303-3298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty