MEDICARE: DR. KENNETH P DAVIS

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	103T00000X	Psychologist	1541	WI
2	103TC0700X	Clinical Psychologist	071-004444	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205040771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH P DAVIS

Provider Business Mailing Address
First Line	:	821 W VAN BUREN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-3517
Country	:	US
Telephone Number	:	312-491-0404
Fax Number	:

Provider Business Practice Location Address
First Line	:	821 W VAN BUREN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-3517
Country	:	US
Telephone Number	:	312-491-0404
Fax Number	:

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	09/11/2025

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Directions to “ DR. KENNETH P DAVIS ” Practice Location

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