MEDICARE: MARY DAVIS LCSW, RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	5062	CT
2	133V00000X	Registered Dietitian	000683	CT
3	1041C0700X	Clinical Social Worker	005062	CT

General Provider Information

NPI Number	:	1457418568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY DAVIS LCSW, RD

Provider Business Mailing Address
First Line	:	34 CONCORD ST
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-2112
Country	:	US
Telephone Number	:	860-657-8742
Fax Number	:	860-899-1272

Provider Business Practice Location Address
First Line	:	34 CONCORD ST
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-2112
Country	:	US
Telephone Number	:	860-657-8742
Fax Number	:	860-899-1272

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	11/01/2023

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