Provider Demographics
NPI:1750657466
Name:DAVIS, MARY A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 BERGER RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-4522
Mailing Address - Country:US
Mailing Address - Phone:270-994-2387
Mailing Address - Fax:
Practice Address - Street 1:234 BERGER RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-9784
Practice Address - Country:US
Practice Address - Phone:270-994-2387
Practice Address - Fax:270-993-1991
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical