Provider Demographics
NPI:1770805962
Name:DAVIS, KRISTINE ANNE (PCC)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:ANNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:MRS
Other - First Name:KRISTINE
Other - Middle Name:ANNE
Other - Last Name:MACVEIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PCC
Mailing Address - Street 1:230 S COURT ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2275
Mailing Address - Country:US
Mailing Address - Phone:330-723-7977
Mailing Address - Fax:330-725-5177
Practice Address - Street 1:230 S COURT ST
Practice Address - Street 2:SUITE 5
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2275
Practice Address - Country:US
Practice Address - Phone:330-723-7977
Practice Address - Fax:330-725-5177
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE3372101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health