Provider Demographics
NPI:1154916559
Name:DAVIS, KIMYATTA M
Entity type:Individual
Prefix:
First Name:KIMYATTA
Middle Name:M
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 1:1797 PITKIN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-7839
Mailing Address - Country:US
Mailing Address - Phone:718-971-1944
Mailing Address - Fax:
Practice Address - Street 1:1797 PITKIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-7839
Practice Address - Country:US
Practice Address - Phone:718-971-1944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY261QM1300XMedicaid