Provider Demographics
NPI:1437568326
Name:DAVIS, TRACY D (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570-H RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146
Mailing Address - Country:US
Mailing Address - Phone:410-975-0067
Mailing Address - Fax:410-975-0204
Practice Address - Street 1:570-H RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146
Practice Address - Country:US
Practice Address - Phone:410-975-0067
Practice Address - Fax:410-975-0204
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7042101YM0800X
MDLGP5664101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD116075300Medicaid