Provider Demographics
NPI:1629526512
Name:DAVIS, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 E WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744-2027
Mailing Address - Country:US
Mailing Address - Phone:662-258-8293
Mailing Address - Fax:
Practice Address - Street 1:156 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2027
Practice Address - Country:US
Practice Address - Phone:662-258-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0267225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist