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General NPI Number Information
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NPI Number | 1134904949
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Entity Type | Individual
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Provider Name | KEITH JAMES DAVIS LPC
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Gender | Male
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Dates
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Enumeration Date | 08/29/2023
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Last Update Date | 05/10/2024
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Provider Practice Location Address
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Address Line | 805 N MAIN ST STE 109
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City | MOSCOW
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State | ID
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Zip | 83843-8513
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Country | US
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Telephone | 208-831-7094
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Fax | 208-418-9816
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Provider Business Mailing Address
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Address Line | 707 BENTZ ST # 252
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City | TROY
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State | ID
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Zip | 83871-0015
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Country | US
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Telephone | 509-592-0902
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 9827
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License Number State | ID
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