Provider Demographics
NPI:1285906966
Name:DAVIS, CODY W (P1511126)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:P1511126
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W MAIN PL STE I
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3510
Mailing Address - Country:US
Mailing Address - Phone:479-453-9964
Mailing Address - Fax:479-500-1353
Practice Address - Street 1:910 W MAIN PL STE I
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3510
Practice Address - Country:US
Practice Address - Phone:479-453-9964
Practice Address - Fax:479-500-1353
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1511126101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional