=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467587766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENYA DAVIS A&D COUNSELOR, TRAIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 E CHURCHVILLE RD SUITE 200
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-420-6572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1107 TACE DR APT. 2B
-----------------------------------------------------
City | ESSEX
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21221-5723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-854-3447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | TRAINEE STATUS
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------