Provider Demographics
NPI:1538649108
Name:DAVIS, BERNICE HENDERSON
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:HENDERSON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 MARGARET PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4521
Mailing Address - Country:US
Mailing Address - Phone:318-675-0406
Mailing Address - Fax:318-675-0408
Practice Address - Street 1:1513 LINE AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-754-3890
Practice Address - Fax:318-658-9012
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568534857OtherNPI
LA1103926Medicaid