Provider Demographics
NPI:1962630350
Name:DAVIS, PATRICIA L (LISAC)
Entity Type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13820 NORTH 51ST AVE
Mailing Address - Street 2:100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-9306
Mailing Address - Country:US
Mailing Address - Phone:623-398-8904
Mailing Address - Fax:623-414-3448
Practice Address - Street 1:13820 NORTH 51ST AVE
Practice Address - Street 2:100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-9306
Practice Address - Country:US
Practice Address - Phone:623-398-8904
Practice Address - Fax:623-414-3448
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11893101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)