Provider Demographics
NPI:1124486477
Name:DAVIS, DEXTER JUAN (EDD LCADC)
Entity type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:JUAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:EDD LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STILES STREET
Mailing Address - Street 2:
Mailing Address - City:VAUXHALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07088
Mailing Address - Country:US
Mailing Address - Phone:908-688-4462
Mailing Address - Fax:908-688-7959
Practice Address - Street 1:360 STILES ST
Practice Address - Street 2:
Practice Address - City:VAUXHALL
Practice Address - State:NJ
Practice Address - Zip Code:07088-1329
Practice Address - Country:US
Practice Address - Phone:908-688-4462
Practice Address - Fax:908-688-7959
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00197500101YA0400X, 101YM0800X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist