Healthcare Provider Details

I. General information

NPI: 1679186670
Provider Name (Legal Business Name): MARTALE JERRELL DAVIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

1670 CLAIRMONT RD # MHSL116
DECATUR GA
30033-4004
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 404-321-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY004407
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: