Healthcare Provider Details

I. General information

NPI: 1114755402
Provider Name (Legal Business Name): MALLORY LEIGH DAVILA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 E 63RD ST STE 240
KANSAS CITY MO
64110-3331
US

IV. Provider business mailing address

633 E 63RD ST STE 240
KANSAS CITY MO
64110-3331
US

V. Phone/Fax

Practice location:
  • Phone: 816-673-6769
  • Fax:
Mailing address:
  • Phone: 816-756-3505
  • Fax: 816-756-3058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2026028712
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: