Healthcare Provider Details

I. General information

NPI: 1770135972
Provider Name (Legal Business Name): T. CONSWELLO DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 HOLLYWOOD BLVD STE 2
HOLLYWOOD FL
33021-6795
US

IV. Provider business mailing address

PO BOX 4223
FORT LAUDERDALE FL
33338-4223
US

V. Phone/Fax

Practice location:
  • Phone: 954-639-7345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18391
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: