| D | |
|
2557 Sherman Oak Dr North Port FL 34289-2390 | |
| (573) 776-0578 | |
| Not Available |
| Full Name | D |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 2557 Sherman Oak Dr, North Port, Florida |
| Authorized Official Name and Position | Roger Dale Davis (OWNER) |
| Authorized Official Contact | 5737760578 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| D 2557 Sherman Oak Dr North Port FL 34289-2390 Ph: (573) 776-0578 | D 2557 Sherman Oak Dr North Port FL 34289-2390 Ph: (573) 776-0578 |
| NPI Number | 1164103446 |
|---|---|
| Provider Enumeration Date | 07/28/2023 |
| Last Update Date | 11/15/2023 |
| Certification Date | 11/15/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164103446 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
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