Basic Information
| Provider Information | |||||||||
| NPI: | 1437568326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 570-H RITCHIE HWY | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109750067 | ||||||||
| FaxNumber: | 4109750204 | ||||||||
| Practice Location | |||||||||
| Address1: | 570-H RITCHIE HWY | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109750067 | ||||||||
| FaxNumber: | 4109750204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2014 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LC7042 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LGP5664 | MD | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 116075300 | 05 | MD | MEDICAID |