Provider Demographics
NPI:1679010326
Name:DAVIS, BRIAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALEXANDER
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 1:7807 NW 187TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5247
Mailing Address - Country:US
Mailing Address - Phone:305-905-9196
Mailing Address - Fax:
Practice Address - Street 1:12051 W OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-2933
Practice Address - Country:US
Practice Address - Phone:305-905-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician