Provider Demographics
NPI:1558778936
Name:DAVIS, WILLIE JR (RKT)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:RKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DUKE AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4060
Mailing Address - Country:US
Mailing Address - Phone:601-550-1164
Mailing Address - Fax:
Practice Address - Street 1:701 DUKE AVE.
Practice Address - Street 2:
Practice Address - City:HATTIESBIURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-550-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1907251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1907OtherAMERICAN KINESIOTHERAPY ASSOCIATION