Provider Demographics
NPI:1679806467
Name:DAVIS, MARC ROBERT (MA)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:ROBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13010 GIRARD AVE S
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2406
Mailing Address - Country:US
Mailing Address - Phone:952-223-1200
Mailing Address - Fax:952-223-1200
Practice Address - Street 1:701 DECATUR AVE N
Practice Address - Street 2:SUITE 109
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4367
Practice Address - Country:US
Practice Address - Phone:763-746-2401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1542106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist