Provider Demographics
NPI:1457418568
Name:DAVIS, MARY (LCSW, RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW, RD
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, RD
Mailing Address - Street 1:34 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2112
Mailing Address - Country:US
Mailing Address - Phone:860-657-8742
Mailing Address - Fax:860-899-1272
Practice Address - Street 1:34 CONCORD ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2112
Practice Address - Country:US
Practice Address - Phone:860-657-8742
Practice Address - Fax:860-899-1272
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT50621041C0700X
CT000683133V00000X
CT0050621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered