Healthcare Provider Details

I. General information

NPI: 1154343499
Provider Name (Legal Business Name): MARY LINDA DAVIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/12/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WILSON RD
LITTLE ROCK AR
72205-6659
US

IV. Provider business mailing address

1301 WILSON RD
LITTLE ROCK AR
72205-6659
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-0576
  • Fax: 501-225-6789
Mailing address:
  • Phone: 501-225-0576
  • Fax: 501-225-6789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR13457
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number764-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: