Provider Demographics
NPI:1912443284
Name:DAVIS, EDEN (BCBA, LPC)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:BCBA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252
Mailing Address - Country:US
Mailing Address - Phone:254-315-4829
Mailing Address - Fax:
Practice Address - Street 1:204 FRONT STREET
Practice Address - Street 2:
Practice Address - City:QUANAH
Practice Address - State:TX
Practice Address - Zip Code:79252
Practice Address - Country:US
Practice Address - Phone:254-315-4829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73850101YM0800X
TX1-16-24503103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty