Provider Demographics
NPI:1710197793
Name:DAVIS, TRACEY DESHON (BSW)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DESHON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 CHATEAU DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-6308
Mailing Address - Country:US
Mailing Address - Phone:501-562-6041
Mailing Address - Fax:
Practice Address - Street 1:4400 SHUFFIELD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7100
Practice Address - Country:US
Practice Address - Phone:501-686-9300
Practice Address - Fax:501-686-9618
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator