Healthcare Provider Details

I. General information

NPI: 1689891434
Provider Name (Legal Business Name): MISTY DAVIS M S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10134 W BROAD ST
GLEN ALLEN VA
23060-3303
US

IV. Provider business mailing address

4425 KILLIAM CT
GLEN ALLEN VA
23060-6486
US

V. Phone/Fax

Practice location:
  • Phone: 804-310-2948
  • Fax:
Mailing address:
  • Phone: 804-527-5206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC017743
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701005217
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: