Basic Information
| Provider Information | |||||||||
| NPI: | 1336183540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | DIANN | ||||||||
| MiddleName: | THERESE | ||||||||
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| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31094 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061501094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009896446 | ||||||||
| FaxNumber: | 5189528287 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 8TH AVE | ||||||||
| Address2: | SUITE 906 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100186504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006228996 | ||||||||
| FaxNumber: | 2123993705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 070764 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01420795 | 05 | NY | MEDICAID |