Provider Demographics
NPI:1093114381
Name:MARK D. DAVIS, LCSW, LLC
Entity Type:Organization
Organization Name:MARK D. DAVIS, LCSW, LLC
Other - Org Name:DAVIS SOUND MIND EAP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-968-3417
Mailing Address - Street 1:3820 NORTHDALE BLVD
Mailing Address - Street 2:SUITE 312 B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1863
Mailing Address - Country:US
Mailing Address - Phone:813-968-3417
Mailing Address - Fax:813-968-5051
Practice Address - Street 1:3820 NORTHDALE BLVD
Practice Address - Street 2:SUITE 312 B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1863
Practice Address - Country:US
Practice Address - Phone:813-968-3417
Practice Address - Fax:813-968-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW39871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3220Medicare UPIN