MEDICARE: INDIA KALA DAVIS LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	101YP2500X	Professional Counselor	180.012922	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1245512219	OTHER	IL	BCBSIL PPO

General Provider Information

NPI Number	:	1245512219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INDIA KALA DAVIS LCPC

Provider Business Mailing Address
First Line	:	4747 S KING DR APT 803
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-1351
Country	:	US
Telephone Number	:	312-927-6642
Fax Number	:

Provider Business Practice Location Address
First Line	:	5113 S HARPER AVE # 2042
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4119
Country	:	US
Telephone Number	:	312-927-6642
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	10/02/2020

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