Provider Demographics
NPI:1851898878
Name:DAVIS, KEITH
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
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 1:24 W 117TH ST APT 9B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1943
Mailing Address - Country:US
Mailing Address - Phone:646-469-8593
Mailing Address - Fax:
Practice Address - Street 1:579 COURTLANDT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5013
Practice Address - Country:US
Practice Address - Phone:718-485-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104574104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker