Provider Demographics
NPI:1417943077
Name:DAVIS, STEPHANIE B (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2377
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-2377
Mailing Address - Country:US
Mailing Address - Phone:276-415-9483
Mailing Address - Fax:276-889-5505
Practice Address - Street 1:320 SWORD ST.
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-415-9483
Practice Address - Fax:276-889-5505
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040026181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945522Medicaid
VA140758OtherBCBS
R76956Medicare UPIN
VA140758OtherBCBS