Provider Demographics
NPI:1578142899
Name:DAVIS, MAKENNA LACEY (CSWA)
Entity Type:Individual
Prefix:MS
First Name:MAKENNA
Middle Name:LACEY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1111
Mailing Address - Country:US
Mailing Address - Phone:541-525-5803
Mailing Address - Fax:
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2099
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA123901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA12390OtherCLINICAL SOCIAL WORK ASSOCIATE