Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 211203 | TX |
NPI | 1003191461 |
---|---|
Provider Name | Brantley Warren Davis |
First Address | Sumrall, MS 39482-4035 |
Second Address | Sumrall, MS 39482-4035 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2011 |
Last Update Date | 18/10/2011 |