Provider Demographics
NPI:1134250616
Name:DAVIS-JOHNSON, DEBRA EDITH (PHD)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:EDITH
Last Name:DAVIS-JOHNSON
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 1:6206 W WIKIEUP LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5207
Mailing Address - Country:US
Mailing Address - Phone:602-290-4824
Mailing Address - Fax:866-663-6564
Practice Address - Street 1:6206 W WIKIEUP LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5207
Practice Address - Country:US
Practice Address - Phone:602-290-4824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
AZ3941103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ331706Medicaid
AZZ132636OtherMEDICARE PTAN