Provider Demographics
NPI:1821434523
Name:POLLEY-DAVIS (WHAYNE), TA'VIONNA DANIELLE
Entity Type:Individual
Prefix:
First Name:TA'VIONNA
Middle Name:DANIELLE
Last Name:POLLEY-DAVIS (WHAYNE)
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 1:4922 NORTH ROSEDALE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74126
Mailing Address - Country:US
Mailing Address - Phone:918-853-5551
Mailing Address - Fax:
Practice Address - Street 1:1148 E. 20TH ST
Practice Address - Street 2:UNIT A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128
Practice Address - Country:US
Practice Address - Phone:918-878-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid