Basic Information
| Provider Information | |||||||||
| NPI: | 1851661920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | BSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 N FEDERAL HWY | ||||||||
| Address2: | SUITE 2S | ||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330646519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888809270 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Practice Location | |||||||||
| Address1: | 914 HARRISON AVENUE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508199543 | ||||||||
| FaxNumber: | 8507478547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2012 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 222Q00000X | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.