Provider Demographics
NPI:1275656126
Name:DAVIS, BARBARA ANN (LSW)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:ANN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 MOHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-6844
Mailing Address - Country:US
Mailing Address - Phone:618-532-5457
Mailing Address - Fax:
Practice Address - Street 1:1035 MOHAWK TRL
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-6844
Practice Address - Country:US
Practice Address - Phone:618-532-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150-008177104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL74-3195237OtherEIN FERDERAL TAX ID NUMBE