Provider Demographics
NPI:1962503060
Name:DAVIS, AMY T (PHD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:T
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 DAWSONVILLE HWY
Mailing Address - Street 2:SUITE 2201
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2610
Mailing Address - Country:US
Mailing Address - Phone:770-534-9100
Mailing Address - Fax:770-534-9104
Practice Address - Street 1:629 DAWSONVILLE HWY
Practice Address - Street 2:SUITE 2201
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2610
Practice Address - Country:US
Practice Address - Phone:770-534-9100
Practice Address - Fax:770-534-9104
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1575103TC0700X, 103TB0200X, 103T00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00484514CMedicaid
GA00484514CMedicaid