=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952915159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRECIOUS EBONY DAVIS CPS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2020
-----------------------------------------------------
Last Update Date | 09/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1119 RICHMOND AVE
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66104-5945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-290-4110
-----------------------------------------------------
Fax | 816-537-8605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 312 SW GREENWICH DR STE 626
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64082-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-602-0106
-----------------------------------------------------
Fax | 816-537-8605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------