Healthcare Provider Details

I. General information

NPI: 1164164190
Provider Name (Legal Business Name): BRAD W DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S MAIN ST
LIMA OH
45804-1240
US

IV. Provider business mailing address

1436 LOWELL AVE
LIMA OH
45805-3118
US

V. Phone/Fax

Practice location:
  • Phone: 567-371-4418
  • Fax:
Mailing address:
  • Phone: 419-230-5067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2207233
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: