Provider Demographics
NPI:1992278923
Name:DAVIS, DAWYA WILSON (MHS)
Entity type:Individual
Prefix:MRS
First Name:DAWYA
Middle Name:WILSON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808
Mailing Address - Country:US
Mailing Address - Phone:225-239-5293
Mailing Address - Fax:225-239-5439
Practice Address - Street 1:2460 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:225-239-5293
Practice Address - Fax:225-239-5439
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA601008607Medicaid