Provider Demographics
NPI:1972735934
Name:DAVIS, MICHELE ELAINE
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:ELAINE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17434 ROY ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-1351
Mailing Address - Country:US
Mailing Address - Phone:708-359-9817
Mailing Address - Fax:708-895-1210
Practice Address - Street 1:17434 ROY ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-1351
Practice Address - Country:US
Practice Address - Phone:708-359-9817
Practice Address - Fax:708-895-1210
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL974440764222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist