Provider Demographics
NPI:1437512738
Name:DAVIS HENDERSON, NATOYA Y (DPC)
Entity type:Individual
Prefix:DR
First Name:NATOYA
Middle Name:Y
Last Name:DAVIS HENDERSON
Suffix:
Gender:F
Credentials:DPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SLIM ST
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-3551
Mailing Address - Country:US
Mailing Address - Phone:662-207-5820
Mailing Address - Fax:
Practice Address - Street 1:2349 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-8337
Practice Address - Country:US
Practice Address - Phone:662-452-5072
Practice Address - Fax:662-452-5073
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2024101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00557303Medicaid