Provider Demographics
NPI:1780365379
Name:DAVIS, WALLACE TERRY
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:TERRY
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 1:3316 BENYARD DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36619-4312
Mailing Address - Country:US
Mailing Address - Phone:251-421-7652
Mailing Address - Fax:
Practice Address - Street 1:3316 BENYARD DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36619-4312
Practice Address - Country:US
Practice Address - Phone:251-421-7652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL192101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional