NPIMap

Individual provider Active NPI

Kenneth P Davis

  • Psychologist
  • Chicago, IL
National Provider Identifier
1205040771
Registry record updated Sep 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
License
1541 Issued in WI
Practice address
821 W Van Buren St
Chicago, IL 60607-3517
Phone
(312) 491-0404
NPI assigned
May 10, 2007
Last updated
Sep 11, 2025By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Psychologist 103T00000X 1541 WI Primary
Clinical Psychologist 103TC0700X 071-004444 IL

Addresses

Primary practice location

821 W Van Buren St
Chicago, IL 60607-3517

Mailing address

821 W Van Buren St
Chicago, IL 60607-3517
Phone (312) 491-0404

Other identifiers 2

IdentifierTypeStateIssuer
036071836MedicaidIL
39010900MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
071-004444ILMDClinical Psychologist
1541WIMDSurgical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Galena Clinic, Inc. Current Accepting new patients
Galena Clinic, Inc. Current Accepting new patients
Pdssc-Chicago, Inc. Current Accepting new patients
Professional Diagnostic Service, S.C. Past Accepting new patients

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178755200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1757548800000",
    "number": "1205040771",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "821 W VAN BUREN ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606073517",
            "telephone_number": "312-491-0404"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "821 W VAN BUREN ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606073517",
            "telephone_number": "312-491-0404"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DAVIS",
        "first_name": "KENNETH",
        "middle_name": "P",
        "name_prefix": "Dr.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-10",
        "last_updated": "2025-09-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "WI",
            "license": "1541",
            "primary": true
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071-004444",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036071836",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "39010900",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.