MEDICARE: MRS. MONCHELLE DENISE DAVIS

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	373H00000X	Day Training/Habilitation Specialist

General Provider Information

NPI Number	:	1942833884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MONCHELLE DENISE DAVIS

Provider Business Mailing Address
First Line	:	9317 MADINA PKWY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1134
Country	:	US
Telephone Number	:	260-418-5962
Fax Number	:

Provider Business Practice Location Address
First Line	:	9317 MADINA PKWY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1134
Country	:	US
Telephone Number	:	260-418-5962
Fax Number	:

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

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	02/19/2020

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