Provider Demographics
NPI:1992536064
Name:DAVIS, KALEAH ROSE (LADC)
Entity type:Individual
Prefix:
First Name:KALEAH
Middle Name:ROSE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:RUSHFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55971-9111
Mailing Address - Country:US
Mailing Address - Phone:507-458-9606
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1789
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN307113101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)