Provider Demographics
NPI:1972866036
Name:DAVIS, DIANE ELIZABETH (LBSW)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:414 S. BURDICK STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-6219
Mailing Address - Country:US
Mailing Address - Phone:269-381-4446
Mailing Address - Fax:269-381-4457
Practice Address - Street 1:414 S BURDICK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-6219
Practice Address - Country:US
Practice Address - Phone:269-381-4446
Practice Address - Fax:269-381-4457
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802068864104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker