Provider Demographics
NPI:1457786998
Name:DAVIS, MARK HENDERSON (LICSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:HENDERSON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5384 STREET NE
Mailing Address - Street 2:COMMUNITY OPTIONS FRIDLEY
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421
Mailing Address - Country:US
Mailing Address - Phone:763-572-0004
Mailing Address - Fax:763-572-1295
Practice Address - Street 1:5384 STREET NE
Practice Address - Street 2:COMMUNITY OPTIONS FRIDLEY
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55421
Practice Address - Country:US
Practice Address - Phone:763-572-0004
Practice Address - Fax:763-572-1295
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN37961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical