Provider Demographics
NPI:1104896745
Name:DAVIS, TIMOTHY WAYNE (LCSW)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 WARD ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-1829
Mailing Address - Country:US
Mailing Address - Phone:877-838-4783
Mailing Address - Fax:888-341-5050
Practice Address - Street 1:283 W BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2302
Practice Address - Country:US
Practice Address - Phone:865-475-8037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3925113Medicare ID - Type Unspecified