Provider Demographics
NPI:1023787389
Name:DAVILA ROMAN, ELIZANNITE MARIE (LADCII)
Entity type:Individual
Prefix:
First Name:ELIZANNITE
Middle Name:MARIE
Last Name:DAVILA ROMAN
Suffix:
Gender:F
Credentials:LADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 MAIN ST STE 415
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1440
Mailing Address - Country:US
Mailing Address - Phone:413-459-8655
Mailing Address - Fax:413-455-2708
Practice Address - Street 1:1380 MAIN ST STE 415
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1440
Practice Address - Country:US
Practice Address - Phone:413-459-8655
Practice Address - Fax:413-455-2708
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20661101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS87753442OtherDRIVERS