MEDICARE: TERESA A DAVIS MA

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1417586868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA A DAVIS MA

Provider Business Mailing Address
First Line	:	11019 LOWER RIVER RD
Second Line	:
City	:	UNION
State	:	KY
Zip	:	41091-9757
Country	:	US
Telephone Number	:	859-512-1594
Fax Number	:

Provider Business Practice Location Address
First Line	:	71 CAVALIER BLVD STE 303
Second Line	:
City	:	FLORENCE
State	:	KY
Zip	:	41042-5172
Country	:	US
Telephone Number	:	859-282-0204
Fax Number	:

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

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	04/07/2020

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