Provider Demographics
NPI:1598382541
Name:DAVIS, COLTON GRANT (DPT)
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:GRANT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3964 GOODMAN RD E STE 111
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8761
Practice Address - Country:US
Practice Address - Phone:662-932-3844
Practice Address - Fax:662-393-8664
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12890225100000X
MSPT7283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist