Provider Demographics
NPI:1194091033
Name:DAVIS, OCTAVIA FAY
Entity type:Individual
Prefix:MRS
First Name:OCTAVIA
Middle Name:FAY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 CANAL ST STE 314
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6082
Mailing Address - Country:US
Mailing Address - Phone:504-483-7243
Mailing Address - Fax:504-483-7264
Practice Address - Street 1:3801 CANAL ST STE 314
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6082
Practice Address - Country:US
Practice Address - Phone:504-483-7243
Practice Address - Fax:504-483-7264
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA251S00000X
LAPLC9407101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA721447520Medicaid