Provider Demographics
NPI:1821867425
Name:DAVIS, DEIDRA D (LCSW)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:D
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 1:4417 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-4786
Mailing Address - Country:US
Mailing Address - Phone:904-551-4953
Mailing Address - Fax:904-683-5678
Practice Address - Street 1:4417 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4786
Practice Address - Country:US
Practice Address - Phone:904-551-4953
Practice Address - Fax:904-683-5678
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW222371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical