Provider Demographics
NPI:1245206028
Name:DAVIS, BETH BREECE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:BREECE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 COPPERMINE RD
Mailing Address - Street 2:SUITE 183
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-6163
Mailing Address - Country:US
Mailing Address - Phone:619-540-3235
Mailing Address - Fax:
Practice Address - Street 1:13800 COPPERMINE RD
Practice Address - Street 2:SUITE 183
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-6163
Practice Address - Country:US
Practice Address - Phone:619-540-3235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004027103TH0004X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist