Healthcare Provider Details

I. General information

NPI: 1043908759
Provider Name (Legal Business Name): RENEE MONIQUE DAVIS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RENEE MONIQUE BULLOCK PSYD

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 FISHER DR
CUMBERLAND MD
21502-6372
US

IV. Provider business mailing address

339 FISHER DR
CUMBERLAND MD
21502-6372
US

V. Phone/Fax

Practice location:
  • Phone: 240-413-8696
  • Fax:
Mailing address:
  • Phone: 240-413-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701015925
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: