Provider Demographics
NPI:1568497857
Name:DAVIS, MARK DANIEL (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 NORTHDALE BLVD
Mailing Address - Street 2:312B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624
Mailing Address - Country:US
Mailing Address - Phone:813-968-3417
Mailing Address - Fax:
Practice Address - Street 1:3820 NORTHDALE BLVD
Practice Address - Street 2:312B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624
Practice Address - Country:US
Practice Address - Phone:813-968-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW39871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23220Medicare ID - Type Unspecified