Provider Demographics
NPI:1336475029
Name:DAVIS, DONNA M (MED)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:M
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:184 DUDLEY ST
Mailing Address - Street 2:SUITE 107LL
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2561
Mailing Address - Country:US
Mailing Address - Phone:617-442-2002
Mailing Address - Fax:617-442-4002
Practice Address - Street 1:184 DUDLEY ST
Practice Address - Street 2:SUITE 107LL
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2561
Practice Address - Country:US
Practice Address - Phone:617-442-2002
Practice Address - Fax:617-442-4002
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health