Provider Demographics
NPI:1790512804
Name:DAVIS, ELICIA (SOCIAL WORK)
Entity type:Individual
Prefix:
First Name:ELICIA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1886 HIGHWAY 43 S
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-9667
Mailing Address - Country:US
Mailing Address - Phone:769-798-4392
Mailing Address - Fax:
Practice Address - Street 1:1886 HIGHWAY 43 S
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-9667
Practice Address - Country:US
Practice Address - Phone:769-798-4392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-14
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.111408104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker