Healthcare Provider Details

I. General information

NPI: 1932429933
Provider Name (Legal Business Name): STEPHEN M. DAVIS LPC, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 HICKORY ST SUITE 304
DALTON GA
30720-8350
US

IV. Provider business mailing address

1622 HICKORY ST SUITE 304
DALTON GA
30720-8350
US

V. Phone/Fax

Practice location:
  • Phone: 706-279-0405
  • Fax: 706-279-4190
Mailing address:
  • Phone: 706-279-0405
  • Fax: 706-279-4190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC000280
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT000469
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: