MEDICARE: MS. MICHELLE ANTOINETTE 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	1012	MT

General Provider Information

NPI Number	:	1912293721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE ANTOINETTE DAVIS LCSW

Provider Business Mailing Address
First Line	:	30 FORT MISSOULA
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-7211
Country	:	US
Telephone Number	:	406-550-1212
Fax Number	:	406-728-6065

Provider Business Practice Location Address
First Line	:	30 FORT MISSOULA
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-7211
Country	:	US
Telephone Number	:	406-550-1212
Fax Number	:	406-728-6065

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

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	07/08/2011

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