Healthcare Provider Details

I. General information

NPI: 1417382375
Provider Name (Legal Business Name): DOMINIQUE DAVIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 ABRECHT PL
FREDERICK MD
21701-4918
US

IV. Provider business mailing address

1630 CORN CRIB PL
FREDERICK MD
21702-1675
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-8263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW025643
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number085815
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32754
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: