Provider Demographics
NPI:1134904949
Name:DAVIS, KEITH JAMES (LPC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 BENTZ ST # 252
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:ID
Mailing Address - Zip Code:83871-0015
Mailing Address - Country:US
Mailing Address - Phone:509-592-0902
Mailing Address - Fax:
Practice Address - Street 1:805 N MAIN ST STE 109
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-8513
Practice Address - Country:US
Practice Address - Phone:208-831-7094
Practice Address - Fax:208-418-9816
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID9827101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional