Provider Demographics
NPI:1356090187
Name:DAVIS, SHAWN LEE
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:LEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-2715
Mailing Address - Country:US
Mailing Address - Phone:607-936-1771
Mailing Address - Fax:
Practice Address - Street 1:323 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4205
Practice Address - Country:US
Practice Address - Phone:607-734-2548
Practice Address - Fax:607-442-1209
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115345104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker