Provider Demographics
NPI:1508420308
Name:DAVIS, TERESA LYNN
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E NORTH BAY ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3871
Mailing Address - Country:US
Mailing Address - Phone:850-612-0628
Mailing Address - Fax:
Practice Address - Street 1:18288 N US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-4400
Practice Address - Country:US
Practice Address - Phone:813-527-9638
Practice Address - Fax:813-867-7288
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-77142106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician