Provider Demographics
NPI:1205088721
Name:DAVIS, KASEY L (PSYD)
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:L
Other - Last Name:BOLK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6812 TARA MANOR DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2151
Mailing Address - Country:US
Mailing Address - Phone:618-973-4108
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD STE 555
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1265
Practice Address - Country:US
Practice Address - Phone:618-506-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2758103T00000X
MO2010022046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43728700Medicaid