=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669987897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATHY L. DAVIES LPC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2017
-----------------------------------------------------
Last Update Date | 12/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 S BROADWAY AVE
-----------------------------------------------------
City | POTEAU
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74953-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-658-5272
-----------------------------------------------------
Fax | 918-658-5272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33170 PLEASANT VALLEY RD
-----------------------------------------------------
City | POTEAU
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74953-7868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-658-5272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPC
-----------------------------------------------------
Name | KATHY L DAVIES
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 918-658-5272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 5767
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------