Healthcare Provider Details

I. General information

NPI: 1134795362
Provider Name (Legal Business Name): MARISSA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E SUPERIOR ST STE 306
CHICAGO IL
60611-2595
US

IV. Provider business mailing address

8701 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

V. Phone/Fax

Practice location:
  • Phone: 312-754-9404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number81525-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.176674
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: