Provider Demographics
NPI:1609076900
Name:DAVIS, KRISTEN CANBY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:CANBY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13606 WOODBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3164
Mailing Address - Country:US
Mailing Address - Phone:501-920-4904
Mailing Address - Fax:
Practice Address - Street 1:521 JACK STEPHENS DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5524
Practice Address - Country:US
Practice Address - Phone:501-686-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187105719Medicaid
AR4A051Medicare PIN