Provider Demographics
NPI:1295285898
Name:DAVIS, CHRISTOPHER JEROME
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JEROME
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 KALISTE SALOOM RD STE 117
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4230
Mailing Address - Country:US
Mailing Address - Phone:337-234-7109
Mailing Address - Fax:
Practice Address - Street 1:4951 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-6156
Practice Address - Country:US
Practice Address - Phone:318-340-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1295285898Medicaid