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NPI Code Detail

MEDICARE: MS. KATHRYN ELLEN DAVIS LCSW

MEDICARE: MS. KATHRYN ELLEN DAVIS LCSW
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
11041C0700XClinical Social Worker149.013758IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1149.013758OTHERILILLINOIS LICENSE

General Provider Information

NPI Number : 1578740510
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. KATHRYN ELLEN DAVIS LCSW
Provider Business Mailing Address
First Line : 909 S RUSSELL ST
Second Line :
City : MARION
State : IL
Zip : 62959-1544
Country : US
Telephone Number : 618-694-1178
Fax Number :
Provider Business Practice Location Address
First Line : 3111 WILLIAMSON COUNTY PKWY
Second Line :
City : MARION
State : IL
Zip : 62959-5235
Country : US
Telephone Number : 618-997-3647
Fax Number : 618-969-9437
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/22/2008
Last Update Date : 08/20/2009

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