Provider Demographics
NPI:1447316765
Name:DAVIS, KIMBLE DYNETTA (LCPC)
Entity type:Individual
Prefix:MS
First Name:KIMBLE
Middle Name:DYNETTA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N WALKERS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:72142-9409
Mailing Address - Country:US
Mailing Address - Phone:870-514-9088
Mailing Address - Fax:
Practice Address - Street 1:701 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2105
Practice Address - Country:US
Practice Address - Phone:870-772-5028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005837101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional