Provider Demographics
NPI:1558125765
Name:DAVIS, TANNA
Entity Type:Individual
Prefix:
First Name:TANNA
Middle Name:
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 1:1761 HERMITAGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-6084
Mailing Address - Country:US
Mailing Address - Phone:660-620-3372
Mailing Address - Fax:
Practice Address - Street 1:1761 HERMITAGE DR
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-6084
Practice Address - Country:US
Practice Address - Phone:660-620-3372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2308019101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health