Provider Demographics
NPI:1578276614
Name:DAVIS, TISHINA (LSW)
Entity Type:Individual
Prefix:MS
First Name:TISHINA
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 1:505 HYLES CT APT 3
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46320-1943
Mailing Address - Country:US
Mailing Address - Phone:219-516-7761
Mailing Address - Fax:
Practice Address - Street 1:900 RIDGE RD STE 1S
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1934
Practice Address - Country:US
Practice Address - Phone:708-637-1672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150109508104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker