Provider Demographics
NPI:1598883902
Name:DAVIS, CONNIE KAYE (BA, MHP)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:KAYE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:BA, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-1609
Mailing Address - Country:US
Mailing Address - Phone:815-440-5895
Mailing Address - Fax:815-284-6611
Practice Address - Street 1:807 MADISON ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-1735
Practice Address - Country:US
Practice Address - Phone:815-440-5895
Practice Address - Fax:815-284-6599
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health