Provider Demographics
NPI:1588715486
Name:DAVIS, MICHAEL W (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2808 FOX MEADOW LANE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9346
Mailing Address - Country:US
Mailing Address - Phone:870-335-2240
Mailing Address - Fax:870-931-4457
Practice Address - Street 1:2808 FOX MEADOW LANE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9346
Practice Address - Country:US
Practice Address - Phone:870-335-2240
Practice Address - Fax:870-931-4457
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR06-07P103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X989OtherBLUE CROSS BLUE SHIELD
AR227670719Medicaid