Provider Demographics
NPI:1619019007
Name:DAVIS, DEMARCUS C (LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:DEMARCUS
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 NICHOLAS CV
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3894
Mailing Address - Country:US
Mailing Address - Phone:901-359-8330
Mailing Address - Fax:901-757-4212
Practice Address - Street 1:1088 ROGERS RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-8546
Practice Address - Country:US
Practice Address - Phone:901-359-8330
Practice Address - Fax:901-757-4212
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2127101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11993318OtherCAQH
TN1520532Medicaid