Provider Demographics
NPI:1962411934
Name:DAVIS, MARY CARLA (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:CARLA
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 1:5873 LAKE RESORT TER APT D201
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-2788
Mailing Address - Country:US
Mailing Address - Phone:423-877-5631
Mailing Address - Fax:423-877-5631
Practice Address - Street 1:5873 LAKE RESORT TER APT D201
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-2788
Practice Address - Country:US
Practice Address - Phone:423-877-5631
Practice Address - Fax:423-877-5631
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30701041C0700X
TN9611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3693461Medicaid
GA80BBGBNMedicare ID - Type UnspecifiedPROVIDER NUMBER