Provider Demographics
NPI:1609487826
Name:DAVIS, GLORIA JEAN (LCSW, PHD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:JEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 N PORTER ST
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160-2640
Mailing Address - Country:US
Mailing Address - Phone:870-830-3409
Mailing Address - Fax:
Practice Address - Street 1:1804 N PORTER ST
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160-2640
Practice Address - Country:US
Practice Address - Phone:870-830-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty