Provider Demographics
NPI:1740427558
Name:DAVIS, DIANA L (PHD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 WASHINGTON ST UNIT 17
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6862
Mailing Address - Country:US
Mailing Address - Phone:360-344-8429
Mailing Address - Fax:
Practice Address - Street 1:1322 WASHINGTON ST UNIT 17
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6862
Practice Address - Country:US
Practice Address - Phone:360-344-8429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60888941103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140800702Medicaid
NM09724249Medicaid
TX140800702Medicaid