Provider Demographics
NPI:1164274940
Name:DAVIS-BODDIE, DIVON L
Entity Type:Individual
Prefix:
First Name:DIVON
Middle Name:L
Last Name:DAVIS-BODDIE
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 1:18330 N 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8343
Mailing Address - Country:US
Mailing Address - Phone:907-378-0463
Mailing Address - Fax:
Practice Address - Street 1:18330 N 79TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8343
Practice Address - Country:US
Practice Address - Phone:907-378-0463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7560699106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician