Provider Demographics
NPI:1447023544
Name:DAVIS, LARRY D JR
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 CLOVER FIELD CIR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-4313
Mailing Address - Country:US
Mailing Address - Phone:412-326-5087
Mailing Address - Fax:
Practice Address - Street 1:13601 OFFICE PL STE 201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4213
Practice Address - Country:US
Practice Address - Phone:703-492-8939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0734005487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health