Provider Demographics
NPI:1063039931
Name:DAVIS, ABBY RENAE
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:RENAE
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 1:1721 E 22ND ST APT 4
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4177
Mailing Address - Country:US
Mailing Address - Phone:308-223-9447
Mailing Address - Fax:
Practice Address - Street 1:3120 OLD FAITHFUL RD STE 100
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5890
Practice Address - Country:US
Practice Address - Phone:307-369-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician