Provider Demographics
NPI:1477997112
Name:DAVIS, STEPHEN COLLIN (OTR)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:COLLIN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-2005
Mailing Address - Country:US
Mailing Address - Phone:315-598-6120
Mailing Address - Fax:315-598-5713
Practice Address - Street 1:5 TOWER DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2005
Practice Address - Country:US
Practice Address - Phone:315-598-6120
Practice Address - Fax:315-598-5713
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006693-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist