Provider Demographics
NPI:1790309003
Name:DAVIS, GARY RALPH (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RALPH
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 1:275 PINE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-9544
Mailing Address - Country:US
Mailing Address - Phone:859-302-7504
Mailing Address - Fax:
Practice Address - Street 1:275 PINE VALLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-9544
Practice Address - Country:US
Practice Address - Phone:859-302-7504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical