Provider Demographics
NPI:1144311242
Name:DAVIS, SALLY M (CISW)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-3007
Mailing Address - Country:US
Mailing Address - Phone:928-554-2010
Mailing Address - Fax:
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:# 730
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-669-3256
Practice Address - Fax:928-669-3252
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW6801064488104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker