Provider Demographics
NPI:1245512219
Name:DAVIS, INDIA KALA (LCPC)
Entity type:Individual
Prefix:
First Name:INDIA
Middle Name:KALA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 S KING DR APT 803
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1351
Mailing Address - Country:US
Mailing Address - Phone:312-927-6642
Mailing Address - Fax:
Practice Address - Street 1:5113 S HARPER AVE # 2042
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4119
Practice Address - Country:US
Practice Address - Phone:312-927-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL180.012922101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1245512219OtherBCBSIL PPO