Provider Demographics
NPI:1124577267
Name:DAVIS, ETHEL (MHS)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 ELMHURST ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-4518
Mailing Address - Country:US
Mailing Address - Phone:318-220-6626
Mailing Address - Fax:
Practice Address - Street 1:2744 ELMHURST ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108-4518
Practice Address - Country:US
Practice Address - Phone:318-220-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor