Provider Demographics
NPI:1013546654
Name:DAVIS, MANDY JO
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:JO
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 CADDO ST STE 6
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5307
Mailing Address - Country:US
Mailing Address - Phone:870-230-8217
Mailing Address - Fax:870-230-8201
Practice Address - Street 1:2607 CADDO ST STE 6
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5307
Practice Address - Country:US
Practice Address - Phone:870-230-8217
Practice Address - Fax:870-230-8201
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2007092101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health