Provider Demographics
NPI:1437167947
Name:DAVIS, THERESA SHOLTIS (O T)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:SHOLTIS
Last Name:DAVIS
Suffix:
Gender:F
Credentials:O T
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:SHOLTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:197 THOMAS JOHNSON DR STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4314
Mailing Address - Country:US
Mailing Address - Phone:301-662-1997
Mailing Address - Fax:
Practice Address - Street 1:197 THOMAS JOHNSON DR STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4314
Practice Address - Country:US
Practice Address - Phone:301-662-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03093225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKBC4H0-61389202OtherBC/BS OF MARYLAND
MDS404-0006OtherCAREFIRST BC/BS
MD167M166FMedicare PIN
DCG00930-00B258H30Medicare PIN