Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1124379078 |
---|---|
Provider Name | Dacia Davison |
First Address | Portland, OR 97229-5442 |
Second Address | Portland, OR 97229-5442 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2012 |
Last Update Date | 01/10/2012 |