MEDICARE: LANA MARLENE DAVIS L.C.S.W.

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	L3513	OR

General Provider Information

NPI Number	:	1699749705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANA MARLENE DAVIS L.C.S.W.

Provider Business Mailing Address
First Line	:	9088 NW KINGLET LN
Second Line	:
City	:	SEAL ROCK
State	:	OR
Zip	:	97376-9755
Country	:	US
Telephone Number	:	541-563-7408
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 BAY STREET
Second Line	:
City	:	WALDPORT
State	:	OR
Zip	:	97394
Country	:	US
Telephone Number	:	541-453-3055
Fax Number	:

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

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	07/08/2007

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