Provider Demographics
NPI:1902656952
Name:DAVIS, DONNA K (T-24-3697)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:K
Last Name:DAVIS
Suffix:
Gender:F
Credentials:T-24-3697
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11022 SE WOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4553
Mailing Address - Country:US
Mailing Address - Phone:503-201-1668
Mailing Address - Fax:541-234-3777
Practice Address - Street 1:11022 SE WOOD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-4553
Practice Address - Country:US
Practice Address - Phone:503-201-1668
Practice Address - Fax:541-234-3777
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-24-3697101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)