Provider Demographics
NPI:1295484558
Name:DAVIS, MADISEN
Entity type:Individual
Prefix:
First Name:MADISEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 WILLAMETTE DR NE STE C
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-1378
Mailing Address - Country:US
Mailing Address - Phone:803-873-1920
Mailing Address - Fax:844-452-1758
Practice Address - Street 1:3231 WILLAMETTE DR NE STE C
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-1378
Practice Address - Country:US
Practice Address - Phone:803-873-1920
Practice Address - Fax:844-452-1758
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician