Provider Demographics
NPI:1164165783
Name:DAVIS, MONIQUE (BS, LPN, MHP)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:BS, LPN, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RED BUD LN
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-1792
Mailing Address - Country:US
Mailing Address - Phone:618-658-3079
Mailing Address - Fax:618-658-2759
Practice Address - Street 1:300 RED BUD LN
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1792
Practice Address - Country:US
Practice Address - Phone:618-658-3079
Practice Address - Fax:618-658-2759
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL043123568164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health