1588202873 NPI number — JOHNNY DAVIS LPC

Table of content: JOHNNY DAVIS LPC (NPI 1588202873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588202873 NPI number — JOHNNY DAVIS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
JOHNNY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588202873
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 WEST MAIN STREET, SUITE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-968-2001
Provider Business Mailing Address Fax Number:
479-964-2075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 HARDIN RD STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72211-3507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-603-2147
Provider Business Practice Location Address Fax Number:
501-603-0324
Provider Enumeration Date:
12/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  P2208005 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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