Provider Demographics
NPI:1184203341
Name:DAVIS, RENITA DERCEL (MSW, MED)
Entity Type:Individual
Prefix:MRS
First Name:RENITA
Middle Name:DERCEL
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSW, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 N MUNICIPAL WAY UNIT 991
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-7939
Mailing Address - Country:US
Mailing Address - Phone:847-668-7456
Mailing Address - Fax:847-356-1306
Practice Address - Street 1:200 W COUNTRY WALK DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-4009
Practice Address - Country:US
Practice Address - Phone:847-668-7456
Practice Address - Fax:847-356-1306
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool