Healthcare Provider Details

I. General information

NPI: 1922588094
Provider Name (Legal Business Name): NATHAN VICTOR DAVIS MSW, LSWAIC, SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 ROAD 44
PASCO WA
99301-2667
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-453-9820
  • Fax: 509-545-6275
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60889540
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC60633484
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61022677
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: