Provider Demographics
NPI:1063461515
Name:DAVIS, MARCUS B (LPA)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPA
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Mailing Address - Street 1:1400 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3551
Mailing Address - Country:US
Mailing Address - Phone:336-667-5151
Mailing Address - Fax:336-838-3133
Practice Address - Street 1:284 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1831
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2585103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107405Medicaid