Provider Demographics
NPI:1588034854
Name:DAVIS, SHIRLENE (LMT)
Entity Type:Individual
Prefix:
First Name:SHIRLENE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1572
Mailing Address - Street 2:
Mailing Address - City:FAIRPLAY
Mailing Address - State:CO
Mailing Address - Zip Code:80440-1572
Mailing Address - Country:US
Mailing Address - Phone:719-838-0725
Mailing Address - Fax:
Practice Address - Street 1:295 5TH STREET
Practice Address - Street 2:#7
Practice Address - City:FAIRPLAY
Practice Address - State:CO
Practice Address - Zip Code:80440
Practice Address - Country:US
Practice Address - Phone:719-838-0725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0012602225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist