Provider Demographics
NPI:1689061251
Name:DAVIS, CALEB
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
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 1:515 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3136
Mailing Address - Country:US
Mailing Address - Phone:309-655-7378
Mailing Address - Fax:309-655-4609
Practice Address - Street 1:515 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3136
Practice Address - Country:US
Practice Address - Phone:309-655-7378
Practice Address - Fax:309-655-4609
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.016847101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor