Provider Demographics
NPI:1093940017
Name:DAVIS, JOSEPH CLINTON
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CLINTON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 UNADILLA ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-1239
Mailing Address - Country:US
Mailing Address - Phone:318-446-4141
Mailing Address - Fax:
Practice Address - Street 1:520 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2312
Practice Address - Country:US
Practice Address - Phone:318-446-4141
Practice Address - Fax:318-446-4141
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA#4948171M00000X, 101YP2500X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner