Provider Demographics
NPI:1013176890
Name:DAVIS, KEN D (CDPT)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6916 W OCTAVE ST
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-2038
Mailing Address - Country:US
Mailing Address - Phone:509-531-3467
Mailing Address - Fax:
Practice Address - Street 1:1305 MANSFIELD ST
Practice Address - Street 2:SUITE 5
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3588
Practice Address - Country:US
Practice Address - Phone:509-942-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00059734101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)