Provider Demographics
NPI:1316412935
Name:DAVIS, VINCENT M (SUDP, LICSWA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:M
Credentials:SUDP, LICSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2304
Mailing Address - Country:US
Mailing Address - Phone:206-464-1570
Mailing Address - Fax:
Practice Address - Street 1:515 3RD AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2304
Practice Address - Country:US
Practice Address - Phone:206-464-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60844073101YA0400X
WACP61367371101YA0400X
WASC614172891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)