Healthcare Provider Details

I. General information

NPI: 1326173840
Provider Name (Legal Business Name): MR. THAD J DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22421 ANDREW JACKSON HWY
MAXTON NC
28364-6721
US

IV. Provider business mailing address

PO BOX 159
SAINT PAULS NC
28384-0159
US

V. Phone/Fax

Practice location:
  • Phone: 910-844-2008
  • Fax:
Mailing address:
  • Phone: 910-865-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: