Provider Demographics
NPI:1639774748
Name:DAVIS, KADISHA
Entity Type:Individual
Prefix:
First Name:KADISHA
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 1:24 RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2919
Mailing Address - Country:US
Mailing Address - Phone:937-269-7643
Mailing Address - Fax:
Practice Address - Street 1:24 RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-2919
Practice Address - Country:US
Practice Address - Phone:937-269-7643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)