Basic Information
| Provider Information | |||||||||
| NPI: | 1740555614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | LINFRED | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 AUTUMN WOODS DR | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290638940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036084046 | ||||||||
| FaxNumber: | 8037814742 | ||||||||
| Practice Location | |||||||||
| Address1: | 2105 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | CAYCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290331524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037966179 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2012 | ||||||||
| LastUpdateDate: | 03/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.