Provider Demographics
NPI:1255844692
Name:DAVIS, AUDREY R (EDD, MSW, LCSW)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:EDD, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BROOKWOOD LN E
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-5517
Mailing Address - Country:US
Mailing Address - Phone:630-863-0408
Mailing Address - Fax:815-714-6220
Practice Address - Street 1:494 W BOUGHTON RD STE 4B
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1881
Practice Address - Country:US
Practice Address - Phone:630-863-0408
Practice Address - Fax:815-714-6220
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
IL149.0196481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool