Healthcare Provider Details

I. General information

NPI: 1861257578
Provider Name (Legal Business Name): KYLE BURTON DAVIS LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 UNIVERSITY AVE W STE 200
SAINT PAUL MN
55104-3435
US

IV. Provider business mailing address

1919 UNIVERSITY AVE W STE 200
SAINT PAUL MN
55104-3435
US

V. Phone/Fax

Practice location:
  • Phone: 651-266-7999
  • Fax: 651-266-7850
Mailing address:
  • Phone: 651-266-7999
  • Fax: 651-266-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22688
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: