Healthcare Provider Details

I. General information

NPI: 1588189385
Provider Name (Legal Business Name): DAVIS CROSLAND VAUGHN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4939 LOWER ROSWELL RD STE 201C
MARIETTA GA
30068-4384
US

IV. Provider business mailing address

4939 LOWER ROSWELL RD STE 201C
MARIETTA GA
30068-4384
US

V. Phone/Fax

Practice location:
  • Phone: 770-578-1519
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW007793
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: