Healthcare Provider Details

I. General information

NPI: 1629904503
Provider Name (Legal Business Name): RYAN ALEXANDER DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 COHO ST STE 204
MADISON WI
53713-4521
US

IV. Provider business mailing address

3101 FISH HATCHERY RD APT 335
FITCHBURG WI
53713-3266
US

V. Phone/Fax

Practice location:
  • Phone: 608-772-4073
  • Fax:
Mailing address:
  • Phone: 830-992-9703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9043-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: