Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
N | 104100000X | Social Worker | 558 | TN |
NPI | 1003472838 |
---|---|
Provider Name | Dr. Chameleon Davis |
First Address | Glendora, MS 38928-2565 |
Second Address | Glendora, MS 38928-2565 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2019 |
Last Update Date | 16/12/2020 |