Provider Demographics
NPI:1699114082
Name:DAVIS, MARK DAVID (LSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17500 CLOVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6587
Mailing Address - Country:US
Mailing Address - Phone:708-274-6126
Mailing Address - Fax:
Practice Address - Street 1:19201 S LA GRANGE RD STE 204
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8014
Practice Address - Country:US
Practice Address - Phone:708-287-0816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD12054490233103K00000X
IL25361511041S0200X
IL150.116888104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool