Provider Demographics
NPI:1467982314
Name:DAVIS, MARIAH LEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARIAH
Middle Name:LEE
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 1:228 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-2545
Mailing Address - Country:US
Mailing Address - Phone:732-609-5419
Mailing Address - Fax:
Practice Address - Street 1:254 DALEVILLE HIGHWAY
Practice Address - Street 2:
Practice Address - City:COVINGTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18444
Practice Address - Country:US
Practice Address - Phone:570-904-7363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW133935104100000X
PACW0208981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAUNKNOWNOtherUNKNOWN
PACW020898Medicaid