Provider Demographics
NPI:1992916431
Name:DAVIS, MICHELLE ANDREA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANDREA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-0657
Mailing Address - Country:US
Mailing Address - Phone:631-981-2905
Mailing Address - Fax:
Practice Address - Street 1:30 BRANDY AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2316
Practice Address - Country:US
Practice Address - Phone:631-981-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker