Provider Demographics
NPI:1386010528
Name:DAVOS, ATHENA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:DAVOS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 GRAYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02132-2507
Mailing Address - Country:US
Mailing Address - Phone:617-417-3885
Mailing Address - Fax:
Practice Address - Street 1:75 FORSYTH STREET
Practice Address - Street 2:NORTHEASTERN UNIVERISTY SUITE 165G
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-373-8475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2267837163W00000X, 363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health