Provider Demographics
NPI:1063712933
Name:DAVIS, KRISTINA LYNN (LMSW)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13904 BEATRICE ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-4471
Mailing Address - Country:US
Mailing Address - Phone:248-470-7764
Mailing Address - Fax:
Practice Address - Street 1:13904 BEATRICE ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-4471
Practice Address - Country:US
Practice Address - Phone:248-470-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010626741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801062674OtherLMSW