Provider Demographics
NPI:1124232731
Name:DAVIS, PHYLLIS (CDP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 S 152ND ST APT 305
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98148-1040
Mailing Address - Country:US
Mailing Address - Phone:253-839-6261
Mailing Address - Fax:
Practice Address - Street 1:236 S 152ND ST APT 305
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98148-1040
Practice Address - Country:US
Practice Address - Phone:253-839-6261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003526101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)