Provider Demographics
NPI:1295911204
Name:DAVIS, SAMUEL C JR (MAED, LPC)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:C
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:MAED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29086 JORDAN POND DR
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-6419
Mailing Address - Country:US
Mailing Address - Phone:704-982-1266
Mailing Address - Fax:
Practice Address - Street 1:29086 JORDAN POND DR
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-6419
Practice Address - Country:US
Practice Address - Phone:704-982-1266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2642101Y00000X, 101YM0800X, 101YP2500X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional