Provider Demographics
NPI:1194748699
Name:DAVIS, PATRICK (PHD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9433
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-9433
Mailing Address - Country:US
Mailing Address - Phone:406-899-0522
Mailing Address - Fax:406-543-1290
Practice Address - Street 1:300 W BROADWAY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4126
Practice Address - Country:US
Practice Address - Phone:406-899-0522
Practice Address - Fax:406-543-1290
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT236103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT492856Medicaid
MT5342Medicare ID - Type Unspecified