Provider Demographics
NPI:1003366337
Name:DAVIS, LISA M (LMHC, PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMHC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8820
Mailing Address - Country:US
Mailing Address - Phone:941-737-8897
Mailing Address - Fax:
Practice Address - Street 1:351 6TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8820
Practice Address - Country:US
Practice Address - Phone:941-737-8897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4468101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health