Provider Demographics
NPI:1639178759
Name:DAVIS, RICHARD E (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:E
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:PO BOX 380
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-0380
Mailing Address - Country:US
Mailing Address - Phone:207-564-7106
Mailing Address - Fax:207-564-0881
Practice Address - Street 1:59 RIVER ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1322
Practice Address - Country:US
Practice Address - Phone:207-564-7106
Practice Address - Fax:207-564-0881
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC38641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S22349Medicare UPIN
MEMM6310Medicare ID - Type Unspecified