Provider Demographics
NPI:1740662626
Name:DAVIS, MARY LOUISE (MHS, CCFC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MHS, CCFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8033 OLD YORK ROAD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027
Mailing Address - Country:US
Mailing Address - Phone:215-696-7259
Mailing Address - Fax:215-710-0905
Practice Address - Street 1:2514 NORTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133
Practice Address - Country:US
Practice Address - Phone:215-899-8915
Practice Address - Fax:215-226-1278
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional