Healthcare Provider Details

I. General information

NPI: 1356409148
Provider Name (Legal Business Name): JOHN T DAVIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 MAIN STREET STE 210
BAKER CITY OR
97814-2419
US

IV. Provider business mailing address

1201 MAIN ST STE 210
BAKER CITY OR
97814-2419
US

V. Phone/Fax

Practice location:
  • Phone: 541-403-1251
  • Fax: 541-523-5288
Mailing address:
  • Phone: 541-403-1251
  • Fax: 541-523-5288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3473
License Number StateOR

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: