=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134781446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA SHALYNN DAVIS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2019
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 182 16TH ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80807-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-346-9481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 IOWA AVE
-----------------------------------------------------
City | STRATTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80836-1312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-349-0147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW.09925958
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------