Provider Demographics
NPI:1730639659
Name:DAVIS, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 CARTER ST # B
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3143
Mailing Address - Country:US
Mailing Address - Phone:318-414-3065
Mailing Address - Fax:318-414-3067
Practice Address - Street 1:1644 CARTER ST # B
Practice Address - Street 2:SUITE 2
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3143
Practice Address - Country:US
Practice Address - Phone:318-414-3065
Practice Address - Fax:318-414-3067
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health