Healthcare Provider Details

I. General information

NPI: 1770565269
Provider Name (Legal Business Name): TIMOTHY L DAVIS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1743 SYCAMORE AVE
KINGMAN AZ
86409-0927
US

IV. Provider business mailing address

1743 SYCAMORE AVE
KINGMAN AZ
86409
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-8111
  • Fax: 928-757-3256
Mailing address:
  • Phone: 928-757-8111
  • Fax: 928-757-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC 10479
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: