Healthcare Provider Details

I. General information

NPI: 1396217790
Provider Name (Legal Business Name): KYLIE LOUISE DAVIS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2018
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 4TH ST E STE 555
SAINT PAUL MN
55101-2538
US

IV. Provider business mailing address

5804 126TH ST W
APPLE VALLEY MN
55124-8224
US

V. Phone/Fax

Practice location:
  • Phone: 651-333-4074
  • Fax: 715-802-6332
Mailing address:
  • Phone: 651-246-1033
  • Fax: 715-802-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20040
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: