Provider Demographics
NPI:1275126930
Name:DAVIS, LAVONTRE (BEHAVIOR THERAPIST)
Entity Type:Individual
Prefix:
First Name:LAVONTRE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:BEHAVIOR THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 PINTAIL DR STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6738
Mailing Address - Country:US
Mailing Address - Phone:217-572-2286
Mailing Address - Fax:
Practice Address - Street 1:3921 PINTAIL DR STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6738
Practice Address - Country:US
Practice Address - Phone:217-572-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician