1457786998 NPI number — MR. MARK HENDERSON DAVIS LICSW

Table of content: MR. MARK HENDERSON DAVIS LICSW (NPI 1457786998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457786998 NPI number — MR. MARK HENDERSON DAVIS LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
MARK
Provider Middle Name:
HENDERSON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
M

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:
1457786998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5384 STREET NE
Provider Second Line Business Mailing Address:
COMMUNITY OPTIONS FRIDLEY
Provider Business Mailing Address City Name:
FRIDLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-572-0004
Provider Business Mailing Address Fax Number:
763-572-1295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5384 STREET NE
Provider Second Line Business Practice Location Address:
COMMUNITY OPTIONS FRIDLEY
Provider Business Practice Location Address City Name:
FRIDLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-572-0004
Provider Business Practice Location Address Fax Number:
763-572-1295
Provider Enumeration Date:
09/03/2013

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:  3796 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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