Provider Demographics
NPI:1871895516
Name:DAVIS, BRET B (LSAC)
Entity type:Individual
Prefix:MR
First Name:BRET
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 W 210 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-4526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6962782-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)