Provider Demographics
NPI:1316557432
Name:DAVIS, MARY REBEKAH (LCADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:REBEKAH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROY WILKINS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2072
Mailing Address - Country:US
Mailing Address - Phone:502-583-4092
Mailing Address - Fax:
Practice Address - Street 1:645 S ROY WILKINS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2072
Practice Address - Country:US
Practice Address - Phone:502-583-4092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261521101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)