Provider Demographics
NPI:1760509731
Name:DAVIS, JUDITH TERRY (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:TERRY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 OLD HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2526
Mailing Address - Country:US
Mailing Address - Phone:631-421-4174
Mailing Address - Fax:631-421-4174
Practice Address - Street 1:27 OLD HICKORY LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2526
Practice Address - Country:US
Practice Address - Phone:631-421-4174
Practice Address - Fax:631-421-4174
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6245103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV16891Medicare ID - Type Unspecified