Healthcare Provider Details

I. General information

NPI: 1548106040
Provider Name (Legal Business Name): MS. GEORGETTA J DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 S EUCLID AVE 2 FL
OAK PARK IL
60304
US

IV. Provider business mailing address

813 S EUCLID AVE 2 FL
OAK PARK IL
60304
US

V. Phone/Fax

Practice location:
  • Phone: 708-567-0227
  • Fax:
Mailing address:
  • Phone: 708-567-0227
  • Fax: 708-567-0227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.018209
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: