Provider Demographics
NPI:1104370865
Name:DAVIS, RICHARD JR (CAC II, NCAC I)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:CAC II, NCAC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 PROMENADE PL
Mailing Address - Street 2:APT 101
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-7280
Mailing Address - Country:US
Mailing Address - Phone:301-848-6074
Mailing Address - Fax:
Practice Address - Street 1:3485 PROMENADE PL
Practice Address - Street 2:APT 101
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-7280
Practice Address - Country:US
Practice Address - Phone:301-848-6074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCACII1201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)