Provider Demographics
NPI:1609465426
Name:DAVIS, ANTHONY DARNELL
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DARNELL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CATAWBA ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1825
Mailing Address - Country:US
Mailing Address - Phone:161-775-6086
Mailing Address - Fax:
Practice Address - Street 1:50 CATAWBA ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1825
Practice Address - Country:US
Practice Address - Phone:617-756-0865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS97538252106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician