Healthcare Provider Details

I. General information

NPI: 1003394503
Provider Name (Legal Business Name): LAWONDA MANETTE DAVIS MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 RUNNING WATERS CT
WELDON SPRING MO
63304-2413
US

IV. Provider business mailing address

13 RUNNING WATERS CT
WELDON SPRING MO
63304-2413
US

V. Phone/Fax

Practice location:
  • Phone: 636-699-0636
  • Fax:
Mailing address:
  • Phone: 636-699-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2020037394
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11637
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2020037394
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: