Provider Demographics
NPI:1407923048
Name:DAVIS, MISTY DELAINE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:DELAINE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MOUNT TABOR CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-7133
Mailing Address - Country:US
Mailing Address - Phone:678-343-3380
Mailing Address - Fax:
Practice Address - Street 1:2015 VAUGHN RD NW
Practice Address - Street 2:SUITE 130
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7801
Practice Address - Country:US
Practice Address - Phone:770-425-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003187225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics