Healthcare Provider Details

I. General information

NPI: 1336435718
Provider Name (Legal Business Name): MR. GARY S DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 649
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-3741
  • Fax: 928-729-8943
Mailing address:
  • Phone: 928-729-3741
  • Fax: 928-729-8943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number303490
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number303490
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: