Provider Demographics
NPI:1841709268
Name:DAVIS, THEODORE JOSEPH IV
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOSEPH
Last Name:DAVIS
Suffix:IV
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 1:9150 BEREFORD DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2403
Mailing Address - Country:US
Mailing Address - Phone:225-960-7689
Mailing Address - Fax:
Practice Address - Street 1:9150 BEREFORD DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2403
Practice Address - Country:US
Practice Address - Phone:225-960-7688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician