Provider Demographics
NPI:1750047650
Name:DAVIS, SIMONE SHARLOTTE (LMSW)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:SHARLOTTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 BRANDYWINE PL
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6026
Mailing Address - Country:US
Mailing Address - Phone:203-800-1522
Mailing Address - Fax:
Practice Address - Street 1:1226 DANTIGNAC ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2788
Practice Address - Country:US
Practice Address - Phone:706-366-1466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QF0400X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)