Provider Demographics
NPI:1306140827
Name:DAVIS, KELLY S (PHD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1795 W BROADWAY ST # 125
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3045
Mailing Address - Country:US
Mailing Address - Phone:414-759-9678
Mailing Address - Fax:
Practice Address - Street 1:1795 W BROADWAY ST # 125
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3045
Practice Address - Country:US
Practice Address - Phone:414-759-9678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203118103TC0700X
CAPSY35176103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical