Provider Demographics
NPI:1699866830
Name:DAVIS, TERESA R (CRC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 W 800 S
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:IN
Mailing Address - Zip Code:46792-9258
Mailing Address - Country:US
Mailing Address - Phone:260-468-2446
Mailing Address - Fax:
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILC 043780101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)