Provider Demographics
NPI:1356789531
Name:DAVIS, BENJAMIN PHILLIP
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:PHILLIP
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 1:1126 BREEZY LN
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-8659
Mailing Address - Country:US
Mailing Address - Phone:606-875-1420
Mailing Address - Fax:
Practice Address - Street 1:1126 BREEZY LN
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-8659
Practice Address - Country:US
Practice Address - Phone:606-875-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251789103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY251789OtherKENTUCKY APPLIED BEHAVIOR ANALYST LICENSING BOARD