Provider Demographics
NPI:1053916338
Name:DAVIS, TRACEY LEH (SHARED LIVING)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SHARED LIVING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MELVIN DOWNARD RD
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-9232
Mailing Address - Country:US
Mailing Address - Phone:740-988-8400
Mailing Address - Fax:
Practice Address - Street 1:207 MELVIN DOWNARD RD
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-9232
Practice Address - Country:US
Practice Address - Phone:740-988-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105257068499Medicaid