Provider Demographics
NPI:1134781446
Name:DAVIS, KRISTA SHALYNN (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:SHALYNN
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 1:430 IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:STRATTON
Mailing Address - State:CO
Mailing Address - Zip Code:80836-1312
Mailing Address - Country:US
Mailing Address - Phone:719-349-0147
Mailing Address - Fax:
Practice Address - Street 1:182 16TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1649
Practice Address - Country:US
Practice Address - Phone:719-346-9481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099259581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000181734Medicaid