Provider Demographics
NPI:1720099609
Name:DAVIS, JUDY M (LISW)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9474
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44711-9474
Mailing Address - Country:US
Mailing Address - Phone:330-493-7742
Mailing Address - Fax:
Practice Address - Street 1:6465 REFLECTIONS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2355
Practice Address - Country:US
Practice Address - Phone:614-792-1108
Practice Address - Fax:614-792-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 00023171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS60837Medicare UPIN
OHDASW19332Medicare ID - Type Unspecified