Provider Demographics
NPI:1801304225
Name:DAVIS, SARAH A (MA, LPC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:STATHEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5065
Practice Address - Street 1:520 RYAN ST STE W
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-1894
Practice Address - Country:US
Practice Address - Phone:660-827-2494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042663101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490050385Medicaid