Healthcare Provider Details

I. General information

NPI: 1861959785
Provider Name (Legal Business Name): LISA ELLEN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 TEN ROD RD STE D307B
NORTH KINGSTOWN RI
02852-4180
US

IV. Provider business mailing address

1130 TEN ROD RD STE D307B
NORTH KINGSTOWN RI
02852-4180
US

V. Phone/Fax

Practice location:
  • Phone: 401-227-7915
  • Fax:
Mailing address:
  • Phone: 401-227-7915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9336
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC01238
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: