Provider Demographics
NPI:1518263037
Name:DAVIS, PHILLIP LEE (NCC, LMHC)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:LEE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18219 150TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUDS
Mailing Address - State:IA
Mailing Address - Zip Code:52551-8036
Mailing Address - Country:US
Mailing Address - Phone:641-919-3465
Mailing Address - Fax:
Practice Address - Street 1:120 N HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:IA
Practice Address - Zip Code:52535-7700
Practice Address - Country:US
Practice Address - Phone:641-455-0636
Practice Address - Fax:319-498-4246
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001316101YM0800X
IA00116101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA12837Medicaid