Basic Information
| Provider Information | |||||||||
| NPI: | 1659579696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MILLICENT | ||||||||
| MiddleName: | EVETTE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12700 HILLCREST RD | ||||||||
| Address2: | SUITE 249 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331010 | ||||||||
| FaxNumber: | 9722331099 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 E 103RD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606282807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733713668 | ||||||||
| FaxNumber: | 7733713698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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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 | 149012263 | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 52138 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.