Provider Demographics
NPI:1730553579
Name:DEBRA L. DAVIS, PHD LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:DEBRA L. DAVIS, PHD LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LYNND
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:201-207-6294
Mailing Address - Street 1:10 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-2205
Mailing Address - Country:US
Mailing Address - Phone:201-207-6294
Mailing Address - Fax:201-690-6376
Practice Address - Street 1:179 CEDAR LN
Practice Address - Street 2:F
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4304
Practice Address - Country:US
Practice Address - Phone:201-207-6294
Practice Address - Fax:201-690-6376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00541200251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health