Provider Demographics
NPI:1518289271
Name:DAVIS, TANIKA (LSW)
Entity Type:Individual
Prefix:MISS
First Name:TANIKA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 GLEN ECHO RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2914
Mailing Address - Country:US
Mailing Address - Phone:267-626-3091
Mailing Address - Fax:215-242-9119
Practice Address - Street 1:440 GLEN ECHO RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2914
Practice Address - Country:US
Practice Address - Phone:267-626-3091
Practice Address - Fax:215-242-9119
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW122461104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012180030Medicaid