Healthcare Provider Details

I. General information

NPI: 1881672616
Provider Name (Legal Business Name): LORI ELLEN DAVIS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W SPRINGFIELD AVE SUITE 503
CHAMPAIGN IL
61820-4834
US

IV. Provider business mailing address

201 W SPRINGFIELD AVE SUITE 503
CHAMPAIGN IL
61820-4834
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-8888
  • Fax: 217-398-8887
Mailing address:
  • Phone: 217-398-8888
  • Fax: 217-398-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: