1447627088 NPI number — MS. MARLA ILENE DAVIS HENRY LCSW

Table of content: MS. MARLA ILENE DAVIS HENRY LCSW (NPI 1447627088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447627088 NPI number — MS. MARLA ILENE DAVIS HENRY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS HENRY
Provider First Name:
MARLA
Provider Middle Name:
ILENE
Provider Name Prefix Text:
MS.
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:
DAVISHOFF
Provider Other First Name:
MARLA
Provider Other Middle Name:
ILENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447627088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
647 WICKLOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEERFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-471-3273
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
647 WICKLOW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEERFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60015-4522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-471-3273
Provider Business Practice Location Address Fax Number:
847-948-8742
Provider Enumeration Date:
08/31/2015

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: 1041C0700X , with the licence number:  149.007033 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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