MEDICARE: GLENN DAVIS

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	101YM0800X	Mental Health Counselor	0104003	CO

General Provider Information

NPI Number	:	1841601309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN DAVIS

Provider Business Mailing Address
First Line	:	662 GRANT ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-3507
Country	:	US
Telephone Number	:	303-717-7286
Fax Number	:

Provider Business Practice Location Address
First Line	:	662 GRANT ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-3507
Country	:	US
Telephone Number	:	303-717-7286
Fax Number	:

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

Provider Enumeration Date	:	05/17/2014
Last Update Date	:	05/17/2014

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