Provider Demographics
NPI:1407051980
Name:DAVIS, LYNNETTA MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:LYNNETTA
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4243 N 19TH ST
Mailing Address - Street 2:4929 W FOND DU LAC AVE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6829
Mailing Address - Country:US
Mailing Address - Phone:414-871-6122
Mailing Address - Fax:414-871-2552
Practice Address - Street 1:4243 N 19TH ST
Practice Address - Street 2:4929 WFOND DU LAC AVE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6829
Practice Address - Country:US
Practice Address - Phone:414-871-6122
Practice Address - Fax:414-871-2552
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health