Provider Demographics
NPI:1063956894
Name:DAVIS, LACONYER (MACC, LPC, NCC, CADC)
Entity type:Individual
Prefix:MS
First Name:LACONYER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MACC, LPC, NCC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1473 RING RD
Mailing Address - Street 2:GREAT HEIGHTS FAMILY MEDICINE
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5459
Mailing Address - Country:US
Mailing Address - Phone:312-885-2195
Mailing Address - Fax:
Practice Address - Street 1:1473 RING RD
Practice Address - Street 2:GREAT HEIGHTS FAMILY MEDICINE
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5459
Practice Address - Country:US
Practice Address - Phone:312-885-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178011924101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional