Provider Demographics
NPI:1598385437
Name:DAVIS-TAYLOR, TRACI (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:DAVIS-TAYLOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 VIKING WAY
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2405
Mailing Address - Country:US
Mailing Address - Phone:716-940-9109
Mailing Address - Fax:
Practice Address - Street 1:122 VIKING WAY
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2405
Practice Address - Country:US
Practice Address - Phone:716-940-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086227-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical