Provider Demographics
NPI:1336358951
Name:DAVIS, STELLANDA M (LMSW, MFT)
Entity Type:Individual
Prefix:
First Name:STELLANDA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMSW, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8596 BROZVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-6856
Mailing Address - Country:US
Mailing Address - Phone:662-834-4061
Mailing Address - Fax:
Practice Address - Street 1:17280 HIGHWAY 17 SOUTH
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-0479
Practice Address - Country:US
Practice Address - Phone:662-834-1857
Practice Address - Fax:662-834-4937
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM4543106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST0261OtherMASTER LICENSE SOCIAL WOR
MSM4543OtherLICENSE SOCIAL WORKER