Provider Demographics
NPI:1013087196
Name:DAVIS, TIMOTHY O (LSCSW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:O
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 CANTERBURY DR
Mailing Address - Street 2:STE 300
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2214 CANTERBURY DR
Practice Address - Street 2:STE 300
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2386
Practice Address - Country:US
Practice Address - Phone:785-623-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS22231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100425770AMedicaid
KS069645OtherMEDICARE ID