Provider Demographics
NPI:1073964474
Name:DAVIS, CAROLIN (BCBA)
Entity type:Individual
Prefix:
First Name:CAROLIN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5306 CREEKMUR DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4012
Mailing Address - Country:US
Mailing Address - Phone:863-777-0640
Mailing Address - Fax:
Practice Address - Street 1:5306 CREEKMUR DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4012
Practice Address - Country:US
Practice Address - Phone:863-777-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11622830103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019674300Medicaid