Provider Demographics
NPI:1790451086
Name:DAVIS, AUDREY ANNA (RSA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ANNA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RSA
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:ANNA
Other - Last Name:ELLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RSA
Mailing Address - Street 1:2704 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3112
Mailing Address - Country:US
Mailing Address - Phone:815-720-4991
Mailing Address - Fax:
Practice Address - Street 1:2704 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3112
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor