MEDICARE: LATISA NAOMI DAVIDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1396274270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATISA NAOMI DAVIDSON

Provider Business Mailing Address
First Line	:	434272 STATE HIGHWAY 3
Second Line	:
City	:	FT TOWSON
State	:	OK
Zip	:	74735-7514
Country	:	US
Telephone Number	:	580-775-7506
Fax Number	:

Provider Business Practice Location Address
First Line	:	434272 STATE HIGHWAY 3
Second Line	:
City	:	FT TOWSON
State	:	OK
Zip	:	74735-7514
Country	:	US
Telephone Number	:	580-775-7506
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	07/21/2022

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Directions to “ LATISA NAOMI DAVIDSON ” Practice Location

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