MEDICARE: LISA DAVIS MA,MS,LPC

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	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1598368789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DAVIS MA,MS,LPC

Provider Business Mailing Address
First Line	:	8040 LOUIS DR
Second Line	:
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-7111
Country	:	US
Telephone Number	:	708-955-8451
Fax Number	:

Provider Business Practice Location Address
First Line	:	8040 LOUIS DR
Second Line	:
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-7111
Country	:	US
Telephone Number	:	708-955-8451
Fax Number	:

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

Provider Enumeration Date	:	11/19/2020
Last Update Date	:	05/31/2023

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