Healthcare Provider Details

I. General information

NPI: 1659369007
Provider Name (Legal Business Name): KATHY J. DAVIS PHD, ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MASSACHUSETTS AVE W35-115
CAMBRIDGE MA
02139-4301
US

IV. Provider business mailing address

16 PAUL AVE
DERRY NH
03038-3803
US

V. Phone/Fax

Practice location:
  • Phone: 617-253-4908
  • Fax:
Mailing address:
  • Phone: 603-425-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number11
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number8
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: