Basic Information
| Provider Information | |||||||||
| NPI: | 1851391445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | CAROL | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593015901 | ||||||||
| FaxNumber: | 8593015940 | ||||||||
| Practice Location | |||||||||
| Address1: | 334 THOMAS MORE PKWY | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593015901 | ||||||||
| FaxNumber: | 8593015940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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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 | 1207 | KY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 1207 | KY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 82000423 | 05 | KY | MEDICAID | 0160630 | 05 | OH | MEDICAID |