Healthcare Provider Details

I. General information

NPI: 1619886116
Provider Name (Legal Business Name): MR. CEDRIC LAMONT DAVIS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 SOUTHERN AVE
CAPITOL HEIGHTS MD
20743-5639
US

IV. Provider business mailing address

4411 SOUTHERN AVE
CAPITOL HEIGHTS MD
20743-5639
US

V. Phone/Fax

Practice location:
  • Phone: 240-633-6156
  • Fax:
Mailing address:
  • Phone: 240-633-6156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: