Provider Demographics
NPI:1740771443
Name:DAVIS, ETHEL (RBT)
Entity Type:Individual
Prefix:MS
First Name:ETHEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 COPPERVILLE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-1502
Mailing Address - Country:US
Mailing Address - Phone:240-721-0458
Mailing Address - Fax:
Practice Address - Street 1:3620 COPPERVILLE WAY
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-1502
Practice Address - Country:US
Practice Address - Phone:240-721-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-85706106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician