Provider Demographics
NPI:1215341557
Name:DAVIS, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16688 S 11TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-4204
Mailing Address - Country:US
Mailing Address - Phone:918-408-0309
Mailing Address - Fax:
Practice Address - Street 1:16688 S 11TH WEST AVE
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-4204
Practice Address - Country:US
Practice Address - Phone:918-408-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-15
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health