MEDICARE: TERRY E DAVIS LCSW LLC

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	1041C0700X	Clinical Social Worker	SW10792	FL

General Provider Information

NPI Number	:	1346505112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TERRY E DAVIS LCSW LLC

Provider Business Mailing Address
First Line	:	2701 W OAKLAND PARK BLVD
Second Line	:	225C
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-1388
Country	:	US
Telephone Number	:	954-731-5505
Fax Number	:	954-731-5504

Provider Business Practice Location Address
First Line	:	2701 W OAKLAND PARK BLVD
Second Line	:	225C
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-1388
Country	:	US
Telephone Number	:	954-731-5505
Fax Number	:	954-731-5504

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MR. TERRY DAVIS
Credential	:	LCSW
Telephone Number	:	954-731-5505

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	07/09/2012

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