Basic Information
| Provider Information | |||||||||
| NPI: | 1265794218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | COSTELLO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 383 | ||||||||
| Address2: | |||||||||
| City: | NOEL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648540383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174756459 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2153 E JOYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796360083 | ||||||||
| FaxNumber: | 4796360144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.