Provider Demographics
NPI:1386760387
Name:DAVIS, KIM (PHD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
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 1:11738 OTSEGO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3221
Mailing Address - Country:US
Mailing Address - Phone:310-709-6020
Mailing Address - Fax:
Practice Address - Street 1:16055 VENTURA BLVD STE 1033
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:310-281-6645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPS 2006 098101YM0800X
CAPSY21796103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health