Provider Demographics
NPI:1538287842
Name:DAVIS, SALLY A (CNS AND LCADC)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNS AND LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 CLINTON ST
Mailing Address - Street 2:APT 13
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030
Mailing Address - Country:US
Mailing Address - Phone:201-795-9223
Mailing Address - Fax:201-792-8655
Practice Address - Street 1:831 CLINTON ST
Practice Address - Street 2:APT 13
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030
Practice Address - Country:US
Practice Address - Phone:201-795-9223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00080700101YA0400X
NJ26NC05192400364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6913300Medicaid
NJDA004664Medicare ID - Type Unspecified