Provider Demographics
NPI:1699151605
Name:DAVIS, DANYELLE ANTIONETTE (MED, LPC, BCTMH)
Entity type:Individual
Prefix:MRS
First Name:DANYELLE
Middle Name:ANTIONETTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED, LPC, BCTMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W DEAN KEETON ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1091
Mailing Address - Country:US
Mailing Address - Phone:512-471-3515
Mailing Address - Fax:
Practice Address - Street 1:100 W DEAN KEETON ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1091
Practice Address - Country:US
Practice Address - Phone:512-471-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX86313101YM0800X
MS2228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05279542Medicaid
MS2228OtherLPC