Provider Demographics
NPI:1841868361
Name:DAVIS, LIANE D (LICSW)
Entity type:Individual
Prefix:
First Name:LIANE
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-3221
Mailing Address - Country:US
Mailing Address - Phone:781-639-7713
Mailing Address - Fax:
Practice Address - Street 1:66 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-1737
Practice Address - Country:US
Practice Address - Phone:781-631-8273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1168-SW-LICSW-TEMP1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1168-SW-LICSW-TEMPOtherBOARD OF SOCIAL WORLD-MA