Healthcare Provider Details

I. General information

NPI: 1588715486
Provider Name (Legal Business Name): MICHAEL W DAVIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MIKE DAVIS PH.D.

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 FOX MEADOW LANE
JONESBORO AR
72404-9346
US

IV. Provider business mailing address

2808 FOX MEADOW LANE
JONESBORO AR
72404-9346
US

V. Phone/Fax

Practice location:
  • Phone: 870-335-2240
  • Fax: 870-931-4457
Mailing address:
  • Phone: 870-335-2240
  • Fax: 870-931-4457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number06-07P
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number06-07P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: