Provider Demographics
NPI:1063738375
Name:DAVIS, LEKESHA LEVETTE
Entity type:Individual
Prefix:
First Name:LEKESHA
Middle Name:LEVETTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3966 ARGONNE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2417
Mailing Address - Country:US
Mailing Address - Phone:314-853-2421
Mailing Address - Fax:
Practice Address - Street 1:5647 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-2615
Practice Address - Country:US
Practice Address - Phone:314-531-1770
Practice Address - Fax:314-367-2025
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22679101Y00000X
MO2017016839101Y00000X, 101YP2500X
MS22678101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018205Medicaid
MS362085279OtherINSURANCE