Provider Demographics
NPI:1639342553
Name:DAVIS, DANIEL JR
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DAVIS
Suffix:JR
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 1:104 BIG BEND RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:NV
Mailing Address - Zip Code:89442-9442
Mailing Address - Country:US
Mailing Address - Phone:775-352-6849
Mailing Address - Fax:775-575-3180
Practice Address - Street 1:104 BIG BEND RANCH ROAD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:NV
Practice Address - Zip Code:89442-9442
Practice Address - Country:US
Practice Address - Phone:775-352-6849
Practice Address - Fax:775-575-3180
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004701001Medicaid