Provider Demographics
NPI:1962845636
Name:DAVIS, SHADANA (PSYD, LCSW)
Entity Type:Individual
Prefix:
First Name:SHADANA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 JAYMOR RD
Mailing Address - Street 2:SUITE B-150
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3826
Mailing Address - Country:US
Mailing Address - Phone:215-947-8654
Mailing Address - Fax:215-938-7607
Practice Address - Street 1:928 JAYMOR RD
Practice Address - Street 2:SUITE B-150
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3826
Practice Address - Country:US
Practice Address - Phone:215-947-8654
Practice Address - Fax:215-938-7607
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0161311041C0700X
PAPS018480103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical