Provider Demographics
NPI:1710656988
Name:DAVIS, BRENT (PT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 GRANVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6505
Mailing Address - Country:US
Mailing Address - Phone:614-470-6240
Mailing Address - Fax:614-470-6244
Practice Address - Street 1:156 GRANVILLE ST
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-6505
Practice Address - Country:US
Practice Address - Phone:614-470-6240
Practice Address - Fax:614-470-6244
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17781225100000X
OHPT020120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist