MEDICARE: MRS. BRANDYN ALISA DAVIS ASW

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	1041C0700X	Clinical Social Worker	ASW91553	CA

General Provider Information

NPI Number	:	1689342180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRANDYN ALISA DAVIS ASW

Provider Business Mailing Address
First Line	:	31700 N MITCHELL CREEK RD
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-8347
Country	:	US
Telephone Number	:	530-208-8335
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 S LINCOLN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-4416
Country	:	US
Telephone Number	:	530-208-8335
Fax Number	:

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

Provider Enumeration Date	:	08/31/2021
Last Update Date	:	08/31/2021

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