Provider Demographics
NPI:1699749705
Name:DAVIS, LANA MARLENE (LCSW)
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:MARLENE
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 1:9088 NW KINGLET LN
Mailing Address - Street 2:
Mailing Address - City:SEAL ROCK
Mailing Address - State:OR
Mailing Address - Zip Code:97376-9755
Mailing Address - Country:US
Mailing Address - Phone:541-563-7408
Mailing Address - Fax:
Practice Address - Street 1:525 BAY STREET
Practice Address - Street 2:
Practice Address - City:WALDPORT
Practice Address - State:OR
Practice Address - Zip Code:97394
Practice Address - Country:US
Practice Address - Phone:541-453-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL35131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR118999Medicare ID - Type Unspecified