Provider Demographics
NPI:1356010862
Name:DAVIS, MATTHEW TYLER (LPA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TYLER
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 S LAUREL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-8300
Mailing Address - Country:US
Mailing Address - Phone:606-770-5086
Mailing Address - Fax:
Practice Address - Street 1:95 S LAUREL RD STE 1
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8300
Practice Address - Country:US
Practice Address - Phone:606-770-5086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY271738103T00000X
KY281597103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100773860Medicaid
KY7100773860Medicaid