Healthcare Provider Details

I. General information

NPI: 1912948563
Provider Name (Legal Business Name): MARY A DAVIS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W HAYS ST
BOISE ID
83702-5316
US

IV. Provider business mailing address

1221 W HAYS ST
BOISE ID
83702-5316
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-7358
  • Fax: 208-336-9984
Mailing address:
  • Phone: 208-345-7358
  • Fax: 208-336-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY-275
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: