Provider Demographics
NPI:1790321248
Name:DAVIS, JOSHA (MS)
Entity Type:Individual
Prefix:
First Name:JOSHA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 SW 92ND TER
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33328-4221
Mailing Address - Country:US
Mailing Address - Phone:217-341-4741
Mailing Address - Fax:
Practice Address - Street 1:3307 NORTHLAKE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33403-1703
Practice Address - Country:US
Practice Address - Phone:240-650-0604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16791101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health