Provider Demographics
NPI:1245822030
Name:DAVIS, NOREEN L (HIS)
Entity type:Individual
Prefix:
First Name:NOREEN
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6704 OLD TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-2639
Mailing Address - Country:US
Mailing Address - Phone:260-747-0135
Mailing Address - Fax:
Practice Address - Street 1:6704 OLD TRAIL RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-2639
Practice Address - Country:US
Practice Address - Phone:260-747-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3920252678OtherNONE
3920252678OtherUNKNOWN