Provider Demographics
NPI:1356974018
Name:DAVIS, DOUGLAS STEPHEN JR
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:STEPHEN
Last Name:DAVIS
Suffix:JR
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 1:822 CHICKAMAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-1407
Mailing Address - Country:US
Mailing Address - Phone:796-861-6458
Mailing Address - Fax:706-866-6277
Practice Address - Street 1:822 CHICKAMAUGA AVE
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-1407
Practice Address - Country:US
Practice Address - Phone:706-861-6458
Practice Address - Fax:706-866-6277
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0069101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)