Basic Information
| Provider Information | |||||||||
| NPI: | 1538321468 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4881 NW 8TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523736338 | ||||||||
| FaxNumber: | 3523736144 | ||||||||
| Practice Location | |||||||||
| Address1: | 912 NW 57TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326056425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524313940 | ||||||||
| FaxNumber: | 3524313173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY 7748 | FL | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | KX789 | 01 | FL | MEDICARE | OTHER |