Provider Demographics
NPI:1215387055
Name:DAVIS, JAMES (LICDC-CS, QMHS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LICDC-CS, QMHS
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 108
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-0108
Mailing Address - Country:US
Mailing Address - Phone:740-532-1613
Mailing Address - Fax:740-532-1715
Practice Address - Street 1:700 PARK AVE
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1502
Practice Address - Country:US
Practice Address - Phone:740-532-1613
Practice Address - Fax:740-532-1715
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161116101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0216738Medicaid