Provider Demographics
NPI:1124539077
Name:DAVIS, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
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 1:3258 BUNKER HILL LN
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-1150
Mailing Address - Country:US
Mailing Address - Phone:775-360-6294
Mailing Address - Fax:
Practice Address - Street 1:7000 MAE ANNE AVE APT 1625
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-7137
Practice Address - Country:US
Practice Address - Phone:775-379-0983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health