Provider Demographics
NPI:1376374629
Name:DAVIS, BERTRAM
Entity type:Individual
Prefix:
First Name:BERTRAM
Middle Name:
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 1:8033 SUMMIT PARK DR
Mailing Address - Street 2:
Mailing Address - City:PFAFFTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27040-9840
Mailing Address - Country:US
Mailing Address - Phone:336-618-2125
Mailing Address - Fax:
Practice Address - Street 1:255 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055-4299
Practice Address - Country:US
Practice Address - Phone:336-280-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health