Provider Demographics
NPI:1245353325
Name:DAVIS, TIMOTHY SCOTT (ATC,PTA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:SCOTT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:ATC,PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-3820
Mailing Address - Country:US
Mailing Address - Phone:618-542-4241
Mailing Address - Fax:
Practice Address - Street 1:900 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1230
Practice Address - Country:US
Practice Address - Phone:618-542-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer