Provider Demographics
NPI:1801379706
Name:DAVIS, CARRIE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7765 N 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-3809
Mailing Address - Country:US
Mailing Address - Phone:414-737-2489
Mailing Address - Fax:
Practice Address - Street 1:333 W BROWN DEER RD UNIT G951
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-2372
Practice Address - Country:US
Practice Address - Phone:414-737-2489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801379706Medicaid