Basic Information
| Provider Information | |||||||||
| NPI: | 1538709977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7655936001 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473624311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655212450 | ||||||||
| FaxNumber: | 7655936001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2020 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 99096461A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.