Provider Demographics
NPI:1679936231
Name:DAVIS, PRISCILLA M (MA/MHS/CADC)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA/MHS/CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W 146TH ST
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-1410
Mailing Address - Country:US
Mailing Address - Phone:708-699-9444
Mailing Address - Fax:
Practice Address - Street 1:1909 CHEKER SQ
Practice Address - Street 2:
Practice Address - City:EAST HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1442
Practice Address - Country:US
Practice Address - Phone:708-647-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL27742101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)