Healthcare Provider Details

I. General information

NPI: 1225308174
Provider Name (Legal Business Name): BERTHA DAVIS-WILLIAMS PH.D., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 AIRLINE AVENUE
GRAMERCY LA
70052-0933
US

IV. Provider business mailing address

PO BOX 933
GRAMERCY LA
70052-0933
US

V. Phone/Fax

Practice location:
  • Phone: 225-623-9751
  • Fax: 225-869-8758
Mailing address:
  • Phone: 225-623-9751
  • Fax: 225-869-8758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3629
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: