Provider Demographics
NPI:1063789485
Name:DAVISSON, KRISTIN R (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:R
Last Name:DAVISSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 LAKE ST STE 20
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1147
Mailing Address - Country:US
Mailing Address - Phone:210-201-2776
Mailing Address - Fax:
Practice Address - Street 1:1010 LAKE ST STE 200
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1132
Practice Address - Country:US
Practice Address - Phone:210-201-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008238103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical