Provider Demographics
NPI:1902132772
Name:DAVIS, MARILYN
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 E 46TH ST
Mailing Address - Street 2:SUITE Q-7
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2460
Mailing Address - Country:US
Mailing Address - Phone:317-362-3479
Mailing Address - Fax:
Practice Address - Street 1:2511 E 46TH ST
Practice Address - Street 2:SUITE Q-7
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-2460
Practice Address - Country:US
Practice Address - Phone:317-362-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20901934173C00000X, 174H00000X, 208100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No174H00000XOther Service ProvidersHealth Educator
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation