Provider Demographics
NPI:1710423488
Name:DAVIS, SOPHIE E (LCDCII)
Entity Type:Individual
Prefix:MRS
First Name:SOPHIE
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 RUSH BLVD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44507-1535
Mailing Address - Country:US
Mailing Address - Phone:330-744-1181
Mailing Address - Fax:330-740-2849
Practice Address - Street 1:2151 RUSH BLVD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44507-1535
Practice Address - Country:US
Practice Address - Phone:330-744-1181
Practice Address - Fax:330-740-2849
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH991584324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility