Provider Demographics
NPI:1003023995
Name:DAVIS, MARY J
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
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 1:700 ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-4952
Mailing Address - Country:US
Mailing Address - Phone:318-255-6017
Mailing Address - Fax:318-429-5721
Practice Address - Street 1:OVERTON BROOKS VA MEDICAL CENTER
Practice Address - Street 2:510 E. STONER AVENUE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4295
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:318-429-5721
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5639104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker