Provider Demographics
NPI:1972137370
Name:AGEN-DAVIS, OLIVIA SARAH
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SARAH
Last Name:AGEN-DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SUNNYKING DR
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-6126
Mailing Address - Country:US
Mailing Address - Phone:347-793-8756
Mailing Address - Fax:
Practice Address - Street 1:10015 OLD COLUMBIA RD STE F100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1755
Practice Address - Country:US
Practice Address - Phone:347-793-8756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician