=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225222094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMY DAVIS LPC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2007
-----------------------------------------------------
Last Update Date | 09/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8420 DELMAR BLVD STE. 300
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63124-2170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-398-9036
-----------------------------------------------------
Fax | 314-872-8871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8420 DELMAR BLVD STE. 300
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63124-2170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-398-9036
-----------------------------------------------------
Fax | 314-872-8871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS AMY OLD DAVIS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 314-398-9036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 2001009452
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------