Provider Demographics
NPI:1700955622
Name:DAVIS, LON 'MARK' (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:'MARK'
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-0122
Mailing Address - Country:US
Mailing Address - Phone:573-528-3671
Mailing Address - Fax:573-774-3711
Practice Address - Street 1:20157 SALINA RD.
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583
Practice Address - Country:US
Practice Address - Phone:573-528-3671
Practice Address - Fax:573-774-3711
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002020622101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional