MEDICARE: LYLE DAVIS LCSW

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	SW 10453	FL

General Provider Information

NPI Number	:	1639458102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYLE DAVIS LCSW

Provider Business Mailing Address
First Line	:	1524 ARGYLE DR
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-1542
Country	:	US
Telephone Number	:	954-298-8949
Fax Number	:

Provider Business Practice Location Address
First Line	:	1620 W OAKLAND PARK BLVD STE 403
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-1533
Country	:	US
Telephone Number	:	954-298-8949
Fax Number	:

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

Provider Enumeration Date	:	08/15/2011
Last Update Date	:	08/15/2011

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