Healthcare Provider Details

I. General information

NPI: 1336545185
Provider Name (Legal Business Name): LISA M DAVIS CAC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7121 COLUMBIA GATEWAY DRIVE
COLUMBIA MD
21046
US

IV. Provider business mailing address

8930 STANFORD BOULEVARD
COLUMBIA MD
21045
US

V. Phone/Fax

Practice location:
  • Phone: 410-872-8753
  • Fax: 410-313-6212
Mailing address:
  • Phone: 410-313-6202
  • Fax: 410-313-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC0735
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: