Basic Information
| Provider Information | |||||||||
| NPI: | 1437167947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | SHOLTIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O. T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHOLTIS | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 197 THOMAS JOHNSON DR STE B | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 197 THOMAS JOHNSON DR STE B | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 03093 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | KBC4H0-61389202 | 01 | MD | BC/BS OF MARYLAND | OTHER | S404-0006 | 01 | MD | CAREFIRST BC/BS | OTHER |