Provider Demographics
NPI:1891370201
Name:DAVIS, PHILLIP ALAN (LSW)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:ALAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3874
Mailing Address - Country:US
Mailing Address - Phone:888-928-0212
Mailing Address - Fax:
Practice Address - Street 1:1021 N MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3874
Practice Address - Country:US
Practice Address - Phone:888-928-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical