Healthcare Provider Details

I. General information

NPI: 1063348142
Provider Name (Legal Business Name): TANYA L DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4860 COX RD STE 200
GLEN ALLEN VA
23060-9248
US

IV. Provider business mailing address

4860 COX RD STE 200
GLEN ALLEN VA
23060-9248
US

V. Phone/Fax

Practice location:
  • Phone: 317-222-9888
  • Fax: 317-823-2853
Mailing address:
  • Phone: 317-222-9888
  • Fax: 317-823-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number18972-08-014
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: