Provider Demographics
NPI:1487163572
Name:DAVIS, IVERY
Entity type:Individual
Prefix:MR
First Name:IVERY
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 1:1100 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-4914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PEE DEE MENTAL HEALTH, MARION CLINIC
Practice Address - Street 2:1100 S. MAIN ST.
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-2957
Practice Address - Country:US
Practice Address - Phone:843-321-5082
Practice Address - Fax:843-321-5082
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty