MEDICARE: MR. OGENE LEWIS DAVIS LPC MDIV

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	LPC003621	GA

General Provider Information

NPI Number	:	1972537504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OGENE LEWIS DAVIS LPC MDIV

Provider Business Mailing Address
First Line	:	366 WILKINSON DR. SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30317-0073
Country	:	US
Telephone Number	:	404-373-9885
Fax Number	:	404-297-2600

Provider Business Practice Location Address
First Line	:	778 RAYS RD
Second Line	:	SUITE 106
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3107
Country	:	US
Telephone Number	:	404-292-3600
Fax Number	:	404-297-2600

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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