Provider Demographics
NPI:1356010862
Name:DAVIS, MATTHEW TYLER
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TYLER
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-2042
Mailing Address - Country:US
Mailing Address - Phone:606-401-3535
Mailing Address - Fax:
Practice Address - Street 1:801 MASTER ST STE 2
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1026
Practice Address - Country:US
Practice Address - Phone:606-215-3695
Practice Address - Fax:606-215-3695
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY271738103T00000X
KY281597103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY281597OtherLICENSE NUMBER
KY7100773860Medicaid