Healthcare Provider Details

I. General information

NPI: 1093940017
Provider Name (Legal Business Name): JOSEPH CLINTON DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 OLIVE ST
SHREVEPORT LA
71104-2312
US

IV. Provider business mailing address

589 UNADILLA ST
SHREVEPORT LA
71106-1239
US

V. Phone/Fax

Practice location:
  • Phone: 318-446-4141
  • Fax: 318-446-4141
Mailing address:
  • Phone: 318-446-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number#4948
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number#4948
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: