Healthcare Provider Details

I. General information

NPI: 1891759775
Provider Name (Legal Business Name): LORI KAY DAVIS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 TALCOTT RD STE 206
WILLISTON VT
05495-2075
US

IV. Provider business mailing address

183 TALCOTT RD STE 206
WILLISTON VT
05495-2075
US

V. Phone/Fax

Practice location:
  • Phone: 802-876-1100
  • Fax: 802-876-1101
Mailing address:
  • Phone: 802-876-1100
  • Fax: 802-876-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089-0000396
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: