Provider Demographics
NPI:1487149266
Name:DAVIS, BRANDY LEE
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4559 BENES STREET
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034
Mailing Address - Country:US
Mailing Address - Phone:217-525-8332
Mailing Address - Fax:618-692-5204
Practice Address - Street 1:115 ROTTINGHAM CT STE A
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3677
Practice Address - Country:US
Practice Address - Phone:217-525-8332
Practice Address - Fax:618-692-5204
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
IL1-18-33462103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician