Provider Demographics
NPI:1689771412
Name:DAVIS, BRANDON L (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 4TH AVE WEST
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112
Mailing Address - Country:US
Mailing Address - Phone:641-236-6137
Mailing Address - Fax:641-236-0206
Practice Address - Street 1:200 4TH AVE WEST
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112
Practice Address - Country:US
Practice Address - Phone:641-236-6137
Practice Address - Fax:641-236-0206
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00997103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI16613Medicare ID - Type Unspecified