=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083424907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANICE DAVIS LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2025
-----------------------------------------------------
Last Update Date | 03/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 JEFFERSON HTS
-----------------------------------------------------
City | CATSKILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12414-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-719-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 WORTH AVE
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12534-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-821-2464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 119588
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------