Healthcare Provider Details

I. General information

NPI: 1700955622
Provider Name (Legal Business Name): LON 'MARK' DAVIS LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20157 SALINA RD.
WAYNESVILLE MO
65583
US

IV. Provider business mailing address

PO BOX 122
WAYNESVILLE MO
65583-0122
US

V. Phone/Fax

Practice location:
  • Phone: 573-528-3671
  • Fax: 573-774-3711
Mailing address:
  • Phone: 573-528-3671
  • Fax: 573-774-3711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2002020622
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: