Provider Demographics
NPI:1215664636
Name:DAVIS, KAITLYN ELIZABETH (LSW)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 N BROMLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-1504
Mailing Address - Country:US
Mailing Address - Phone:610-217-1169
Mailing Address - Fax:
Practice Address - Street 1:335 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3808
Practice Address - Country:US
Practice Address - Phone:570-825-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA139132104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty