Healthcare Provider Details

I. General information

NPI: 1659511087
Provider Name (Legal Business Name): SUSAN C DAVIS MENTAL HEALTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KLA-OOK-WA DRIVE
TAHOLAH WA
98587-0219
US

IV. Provider business mailing address

PO BOX 219 1505 KLA-OOK-WA DRIVE
TAHOLAH WA
98587-0219
US

V. Phone/Fax

Practice location:
  • Phone: 360-276-4405
  • Fax: 360-276-4474
Mailing address:
  • Phone: 360-276-4405
  • Fax: 360-276-4474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH00003482
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: