Provider Demographics
NPI:1760193171
Name:DAVIS, BRENDA FAYE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:FAYE
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 1:2285 BENTON RD STE D103
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3465
Mailing Address - Country:US
Mailing Address - Phone:318-584-7197
Mailing Address - Fax:318-584-7080
Practice Address - Street 1:2285 BENTON RD STE D103
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3465
Practice Address - Country:US
Practice Address - Phone:318-584-7197
Practice Address - Fax:318-584-7080
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator