Provider Demographics
NPI:1780461558
Name:DAVIS, LEILA DIANE
Entity type:Individual
Prefix:
First Name:LEILA
Middle Name:DIANE
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 1:511 MAIN ST APT 24
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4253
Mailing Address - Country:US
Mailing Address - Phone:203-841-5647
Mailing Address - Fax:
Practice Address - Street 1:180 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4252
Practice Address - Country:US
Practice Address - Phone:203-394-6529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker