Provider Demographics
NPI:1215218466
Name:DAVIS, OTHA (MSW)
Entity Type:Individual
Prefix:MR
First Name:OTHA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1046
Mailing Address - Country:US
Mailing Address - Phone:662-627-7267
Mailing Address - Fax:662-627-5240
Practice Address - Street 1:1742 CHERYL ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7218
Practice Address - Country:US
Practice Address - Phone:662-627-7267
Practice Address - Fax:662-627-5240
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health