Provider Demographics
NPI:1801330964
Name:DAVIS, CAROLYN AH (LPC-IT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:AH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC-IT
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 11425
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-0425
Mailing Address - Country:US
Mailing Address - Phone:414-731-8175
Mailing Address - Fax:
Practice Address - Street 1:314 NIAGARA AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4128
Practice Address - Country:US
Practice Address - Phone:414-731-8175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3396-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional