Provider Demographics
NPI:1124559307
Name:DAVISWORTH II, DAVID REID (QMHA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:REID
Last Name:DAVISWORTH II
Suffix:
Gender:M
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:541-265-4947
Mailing Address - Fax:541-265-4194
Practice Address - Street 1:51 SW LEE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3823
Practice Address - Country:US
Practice Address - Phone:541-574-5960
Practice Address - Fax:541-265-0601
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA601157-449Medicaid