Provider Demographics
NPI:1972388296
Name:DAVIS, TIMOTHY DWAYNE
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DWAYNE
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 1:2675 MLK JR BLVD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-5899
Mailing Address - Country:US
Mailing Address - Phone:458-215-5464
Mailing Address - Fax:
Practice Address - Street 1:2675 MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5899
Practice Address - Country:US
Practice Address - Phone:458-215-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health