Provider Demographics
NPI:1215043252
Name:DAVIS, JAMES RUSSELL JR (LMHC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 WEST GRANADA BLVD
Mailing Address - Street 2:D-4
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5100
Mailing Address - Country:US
Mailing Address - Phone:386-677-9001
Mailing Address - Fax:
Practice Address - Street 1:555 WEST GRANADA BLVD
Practice Address - Street 2:D-4
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5100
Practice Address - Country:US
Practice Address - Phone:386-677-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4467101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health