1043258882 NPI number — KATHERINE M DAVIS LCSW

Table of content: KATHERINE M DAVIS LCSW (NPI 1043258882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043258882 NPI number — KATHERINE M DAVIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
KATHERINE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043258882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 COLUMBIA ST
Provider Second Line Business Mailing Address:
SUITE 11
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04401-6346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-941-8829
Provider Business Mailing Address Fax Number:
207-825-3827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43 COLUMBIA ST
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-6346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-941-8829
Provider Business Practice Location Address Fax Number:
207-825-3827
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LC3871 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7675142 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 11255707 . This is a "CAQH" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 037459 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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