MEDICARE: KIM M DAVIS-RISLOVE MSSW LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	3356	WI

General Provider Information

NPI Number	:	1114969607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM M DAVIS-RISLOVE MSSW LCSW

Provider Business Mailing Address
First Line	:	PO BOX 1510
Second Line	:
City	:	EAU CLAIRE
State	:	WI
Zip	:	54702-1510
Country	:	US
Telephone Number	:	608-785-0940
Fax Number	:

Provider Business Practice Location Address
First Line	:	895 DETTLOFF DR
Second Line	:
City	:	ARCADIA
State	:	WI
Zip	:	54612-2600
Country	:	US
Telephone Number	:	608-785-0940
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	05/21/2019

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