Provider Demographics
NPI:1679723795
Name:DAVISON, KELLIE MERIDETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:MERIDETH
Last Name:DAVISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:KELLIE
Other - Middle Name:MERIDETH
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PLMSW
Mailing Address - Street 1:6127 HIGHWAY 49 N STE D
Mailing Address - Street 2:
Mailing Address - City:BROOKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72417-8650
Mailing Address - Country:US
Mailing Address - Phone:870-336-2937
Mailing Address - Fax:870-336-2938
Practice Address - Street 1:6127 HIGHWAY 49 N STE D
Practice Address - Street 2:
Practice Address - City:BROOKLAND
Practice Address - State:AR
Practice Address - Zip Code:72417-8650
Practice Address - Country:US
Practice Address - Phone:870-219-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6554-C1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5AR15OtherBCBS
AR173840795Medicaid
AR173840795Medicaid