Provider Demographics
NPI:1205038254
Name:DAVIS, ROBERTA M (MS, NCC, LMHC)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 GOODBURLET RD
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14467-9565
Mailing Address - Country:US
Mailing Address - Phone:585-359-3573
Mailing Address - Fax:
Practice Address - Street 1:340 GOODBURLET RD
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14467-9565
Practice Address - Country:US
Practice Address - Phone:585-359-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003353101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health