Provider Demographics
NPI:1205137478
Name:DAVIDGE, MARY MONISA (COTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MONISA
Last Name:DAVIDGE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MONISA
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:3701 WOODLEA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5033
Mailing Address - Country:US
Mailing Address - Phone:410-961-4415
Mailing Address - Fax:
Practice Address - Street 1:3701 WOODLEA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-5033
Practice Address - Country:US
Practice Address - Phone:410-961-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAO1480224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant