Provider Demographics
NPI:1972092369
Name:DAVIS, AMBER DANIELLE (LCSW)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:DANIELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 MACE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7660
Mailing Address - Country:US
Mailing Address - Phone:573-721-2395
Mailing Address - Fax:
Practice Address - Street 1:2804 FORUM BLVD STE 4
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6322
Practice Address - Country:US
Practice Address - Phone:573-721-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160417001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical