MEDICARE: CHRISTOPHER SEAN DAVIS LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LMSW-38785	ID

General Provider Information

NPI Number	:	1417588922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER SEAN DAVIS LMSW

Provider Business Mailing Address
First Line	:	396 YELLOWSTONE AVE
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-4572
Country	:	US
Telephone Number	:	208-538-3122
Fax Number	:

Provider Business Practice Location Address
First Line	:	396 YELLOWSTONE AVE
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-4572
Country	:	US
Telephone Number	:	208-538-3122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2020
Last Update Date	:	02/03/2020

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