Provider Demographics
NPI:1073668984
Name:DAVIS, CONNIE R (LCSW,LMFT)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW,LMFT
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:R
Other - Last Name:DAVIS-OLDHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW,LMFT
Mailing Address - Street 1:219 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1522
Mailing Address - Country:US
Mailing Address - Phone:812-428-0204
Mailing Address - Fax:812-491-1929
Practice Address - Street 1:819 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1137
Practice Address - Country:US
Practice Address - Phone:812-491-1805
Practice Address - Fax:812-491-1929
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001635A1041C0700X
IN35000822A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN225590AMedicare ID - Type UnspecifiedMEDICARE PART A & B