Provider Demographics
NPI:1457413932
Name:DAVIS, LISA E
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 HIGHWAY 411
Mailing Address - Street 2:
Mailing Address - City:VONORE
Mailing Address - State:TN
Mailing Address - Zip Code:37885-2455
Mailing Address - Country:US
Mailing Address - Phone:423-884-7271
Mailing Address - Fax:423-884-3277
Practice Address - Street 1:1206 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37885-2455
Practice Address - Country:US
Practice Address - Phone:423-884-7271
Practice Address - Fax:423-884-3277
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW0000000508104100000X
TN05081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4045434OtherB.C.B.S.T.N.
TN3693562Medicaid
TN000146732OtherB.C.B.S.T. NUMBER
TN1508351Medicaid
TN1508351Medicaid
TN36935621Medicare PIN