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General NPI Number Information
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NPI Number | 1659728038
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Entity Type | Individual
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Provider Name | RANDI DAVIS LPCIT
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Gender | Female
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Dates
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Enumeration Date | 05/16/2016
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Last Update Date | 05/16/2016
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Provider Practice Location Address
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Address Line | 719 W MAIN ST
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City | WAUTOMA
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State | WI
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Zip | 54982-8503
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Country | US
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Telephone | 920-787-7472
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Fax | 920-787-5458
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Provider Business Mailing Address
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Address Line | 719 W MAIN ST
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City | WAUTOMA
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State | WI
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Zip | 54982-8503
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Country | US
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Telephone | 920-787-7472
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Fax | 920-787-5458
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2935-226
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License Number State | WI
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