MEDICARE: DR. JOANNE DAVILA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	013981	NY

General Provider Information

NPI Number	:	1053513317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOANNE DAVILA PH.D.

Provider Business Mailing Address
First Line	:	DEPARTMENT OF PSYCHOLOGY
Second Line	:	SUNY STONY BROOK
City	:	STONY BROOK
State	:	NY
Zip	:	11794-2500
Country	:	US
Telephone Number	:	631-632-7826
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 CHRISTIAN AVE
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-1201
Country	:	US
Telephone Number	:	631-632-7826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	04/22/2009

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