MEDICARE: COREEN DAVIS LPC

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	101YP2500X	Professional Counselor	PC004305	PA

General Provider Information

NPI Number	:	1760931091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREEN DAVIS LPC

Provider Business Mailing Address
First Line	:	505 YORK RD
Second Line	:	UNIT 4
City	:	JENKINTOWN
State	:	PA
Zip	:	19046-2136
Country	:	US
Telephone Number	:	267-626-2018
Fax Number	:	267-636-5205

Provider Business Practice Location Address
First Line	:	505 YORK RD
Second Line	:	UNIT 4
City	:	JENKINTOWN
State	:	PA
Zip	:	19046-2136
Country	:	US
Telephone Number	:	267-626-2018
Fax Number	:	267-636-5205

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

Provider Enumeration Date	:	09/28/2016
Last Update Date	:	09/28/2016

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