Provider Demographics
NPI:1689647208
Name:DAVIS, JOHN L (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HILTON ST
Mailing Address - Street 2:
Mailing Address - City:PEQUANNOCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07440-1311
Mailing Address - Country:US
Mailing Address - Phone:973-633-8010
Mailing Address - Fax:
Practice Address - Street 1:MONTCLAIR STATE UNIVERSITY
Practice Address - Street 2:1 NORMAL AVE.
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1624
Practice Address - Country:US
Practice Address - Phone:973-655-5250
Practice Address - Fax:973-655-5436
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT00010700225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist