=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992419964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NAOMI J DAVIS LCPC-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2023
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 FOREST AVE STE 103
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-221-0635
-----------------------------------------------------
Fax | 207-221-0634
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 FOREST AVE STE 103
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-221-0635
-----------------------------------------------------
Fax | 207-221-0634
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | XL6323
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------