Provider Demographics
NPI:1558398107
Name:DAVIS, MIEKA LISE (ATC, CMT)
Entity Type:Individual
Prefix:MRS
First Name:MIEKA
Middle Name:LISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ATC, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WORTHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545
Mailing Address - Country:US
Mailing Address - Phone:508-277-4156
Mailing Address - Fax:
Practice Address - Street 1:20 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581
Practice Address - Country:US
Practice Address - Phone:508-277-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7712255A2300X
MA7426225700000X
MA771AT2255A2300X
MA7426MT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist