Provider Demographics
NPI:1497211833
Name:TISDALE-DAVIS, RENA AMI (LICSW)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:AMI
Last Name:TISDALE-DAVIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14909 HEALTH CENTER DR APT 426
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1093
Mailing Address - Country:US
Mailing Address - Phone:443-226-8407
Mailing Address - Fax:
Practice Address - Street 1:14909 HEALTH CENTER DR APT 426
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1093
Practice Address - Country:US
Practice Address - Phone:443-226-8407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500816491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical