Provider Demographics
NPI:1962573014
Name:DAVIS, NEIL (MA)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 ELM ST
Mailing Address - Street 2:STE 4
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-2262
Mailing Address - Country:US
Mailing Address - Phone:802-223-3753
Mailing Address - Fax:802-223-3737
Practice Address - Street 1:174 ELM ST
Practice Address - Street 2:STE 4
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2262
Practice Address - Country:US
Practice Address - Phone:802-223-3753
Practice Address - Fax:802-223-3737
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000636103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005373Medicaid
VT2013186OtherCIGNA ID
VT06228643OtherBLUE CROSS SHIELD #
VT247233OtherMAGELLAN ID
VT959928OtherMVP ID
VT959928OtherMVP ID