Provider Demographics
NPI:1881041911
Name:DAVIS, MARISA YVETTE (LPC)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:YVETTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 WESTCLIFF RD APT 1038
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3174
Mailing Address - Country:US
Mailing Address - Phone:919-924-3969
Mailing Address - Fax:
Practice Address - Street 1:1131 QUEENSBOROUGH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5430
Practice Address - Country:US
Practice Address - Phone:919-924-3969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X, 390200000X
SC7161101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program