Provider Demographics
NPI:1285849497
Name:DAVIS, JULIE (MS)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 4TH AVE NW TRLR 90
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2529
Mailing Address - Country:US
Mailing Address - Phone:405-360-2133
Mailing Address - Fax:405-360-2252
Practice Address - Street 1:2502 CROSSROADS DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2503
Practice Address - Country:US
Practice Address - Phone:580-226-9388
Practice Address - Fax:580-226-9395
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UNDER SUPERVISION103TA0400X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)