Provider Demographics
NPI:1770197840
Name:DAVIS, WENDELL DORCELL
Entity Type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:DORCELL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1507
Mailing Address - Country:US
Mailing Address - Phone:806-239-2399
Mailing Address - Fax:
Practice Address - Street 1:3411 73RD ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1101
Practice Address - Country:US
Practice Address - Phone:806-797-2247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67546101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional