Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1225781289 |
---|---|
Provider Name | Myria Jessika Davis |
First Address | Fort Collins, CO 80525-5539 |
Second Address | Fort Collins, CO 80525-5539 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2022 |
Last Update Date | 31/01/2022 |