Provider Demographics
NPI:1154343499
Name:DAVIS, MARY LINDA (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LINDA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6659
Mailing Address - Country:US
Mailing Address - Phone:501-225-0576
Mailing Address - Fax:501-225-6789
Practice Address - Street 1:1301 WILSON RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6659
Practice Address - Country:US
Practice Address - Phone:501-225-0576
Practice Address - Fax:501-225-6789
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR13457163WP0809X
AR764-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
211768OtherVALUE OPTIONS
278210000OtherMAGELLAN
093594OtherMHN
1054808OtherCIGNA