Provider Demographics
NPI:1881826337
Name:DAVIS, ANNETTA JEAN (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:ANNETTA
Middle Name:JEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 CLYO RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459
Mailing Address - Country:US
Mailing Address - Phone:513-310-7293
Mailing Address - Fax:937-938-5249
Practice Address - Street 1:7950 CLYO ROAD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:513-310-7293
Practice Address - Fax:937-938-5249
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11011551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS 1616100156OtherGROUP MEDICARE NUMBER H161280