Provider Demographics
NPI:1134147283
Name:DAVIS, STEPHEN P (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:P
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SE MIDPORT RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4823
Mailing Address - Country:US
Mailing Address - Phone:772-398-1003
Mailing Address - Fax:772-398-1772
Practice Address - Street 1:2400 SE MIDPORT RD
Practice Address - Street 2:SUITE 211
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4823
Practice Address - Country:US
Practice Address - Phone:772-398-1003
Practice Address - Fax:772-398-1772
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5785103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL125175OtherVALUE OPTIONS
FL5170247OtherAETNA
FL82322OtherCIGNA
FL54434OtherBC/BS
FLIP029180OtherMAGELLAN PROVIDER NUMBER
FL54434OtherBC/BS
FL82322OtherCIGNA