Provider Demographics
NPI:1902562101
Name:DAVIS, MARISHA S
Entity Type:Individual
Prefix:
First Name:MARISHA
Middle Name:S
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 1:5007 W FAIRY CHASM CT
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1406
Mailing Address - Country:US
Mailing Address - Phone:414-595-0890
Mailing Address - Fax:
Practice Address - Street 1:5007 W FAIRY CHASM CT
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-1406
Practice Address - Country:US
Practice Address - Phone:414-595-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3568832405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional