Provider Demographics
NPI:1891372561
Name:DAVIS, LISA DANIELLE (SUDPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DANIELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18801 SE 18TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9775
Mailing Address - Country:US
Mailing Address - Phone:360-984-8800
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3713
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator