Basic Information
| Provider Information | |||||||||
| NPI: | 1649338690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | LANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 689 | ||||||||
| Address2: | |||||||||
| City: | CALERA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350400689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059823187 | ||||||||
| FaxNumber: | 2057558882 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CLANTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350452332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059823187 | ||||||||
| FaxNumber: | 2057558882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 01/25/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1911C | AL | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.