MEDICARE: DR. LEIF ERIKSEN DAVIS PSYD

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	103TC0700X	Clinical Psychologist	PY6304	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	130867	OTHER	SC	VALUE OPTIONS ID
2	0001056461	OTHER	FL	MANAGED HEALTH NETWORK ID
3	1381886	OTHER	FL	AETNA ID

General Provider Information

NPI Number	:	1720163835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEIF ERIKSEN DAVIS PSYD

Provider Business Mailing Address
First Line	:	7353 W SAND LAKE RD
Second Line	:	STE 202
City	:	ORLANDO
State	:	FL
Zip	:	32819-5258
Country	:	US
Telephone Number	:	407-351-5660
Fax Number	:	407-363-6707

Provider Business Practice Location Address
First Line	:	7353 W SAND LAKE RD
Second Line	:	STE 202
City	:	ORLANDO
State	:	FL
Zip	:	32819-5258
Country	:	US
Telephone Number	:	407-351-5660
Fax Number	:	407-363-6707

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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