Healthcare Provider Details

I. General information

NPI: 1104519198
Provider Name (Legal Business Name): BROOKLYN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 W JEFFERSON AVE
LAKEWOOD CO
80235-2031
US

IV. Provider business mailing address

6536 S KINGSTON DR
SOUTH WEBER UT
84405-7246
US

V. Phone/Fax

Practice location:
  • Phone: 303-225-7673
  • Fax:
Mailing address:
  • Phone: 801-814-8593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: