Basic Information
| Provider Information | |||||||||
| NPI: | 1063738375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LEKESHA | ||||||||
| MiddleName: | LEVETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3966 ARGONNE FOREST DR | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630342417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148532421 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5647 DELMAR BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631122615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145311770 | ||||||||
| FaxNumber: | 3143672025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 22679 | MS | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | 2017016839 | MO | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 22678 | MS | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 22678 | MS | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YP2500X | 2017016839 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 00018205 | 05 | MS | MEDICAID | 362085279 | 01 | MS | INSURANCE | OTHER |