Provider Demographics
NPI:1952808438
Name:DAVIS, MIESHA
Entity Type:Individual
Prefix:
First Name:MIESHA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-6325
Mailing Address - Country:US
Mailing Address - Phone:848-234-7981
Mailing Address - Fax:
Practice Address - Street 1:513 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-6325
Practice Address - Country:US
Practice Address - Phone:848-234-7981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD09215466461912Medicaid