Provider Demographics
NPI:1922588094
Name:DAVIS, NATHAN VICTOR (MSW, LSWAIC, SUDPT)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:VICTOR
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MSW, LSWAIC, SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:1608 ROAD 44
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-2667
Practice Address - Country:US
Practice Address - Phone:509-453-9820
Practice Address - Fax:509-545-6275
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60889540101YA0400X
101YM0800X
WASC606334841041C0700X
WALW610226771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty