=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609904242
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE E. DAVIS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 WYLLYS ST
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-2720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-524-6890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 GOODRICH RD
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-659-2368
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 005328
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------