Provider Demographics
NPI:1013356807
Name:DAVIS, DIANE (LICENSED MENTAL HEAL)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LICENSED MENTAL HEAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 W 37TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1562
Mailing Address - Country:US
Mailing Address - Phone:718-954-5553
Mailing Address - Fax:718-266-4506
Practice Address - Street 1:2803 W 37TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1562
Practice Address - Country:US
Practice Address - Phone:718-954-5553
Practice Address - Fax:718-266-4506
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003096-1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor