Provider Demographics
NPI:1538413604
Name:DAVIS, RENEE J (LMT)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-0415
Mailing Address - Country:US
Mailing Address - Phone:708-602-6750
Mailing Address - Fax:
Practice Address - Street 1:26011 COMPASS RD
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-8077
Practice Address - Country:US
Practice Address - Phone:708-602-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227012600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist