Provider Demographics
NPI:1215295027
Name:DAVIS, KRISTEN LYNN (LCSW-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 ANNAPOLIS RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1397
Mailing Address - Country:US
Mailing Address - Phone:410-672-2862
Mailing Address - Fax:
Practice Address - Street 1:1202 ANNAPOLIS RD
Practice Address - Street 2:SUITE F
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1397
Practice Address - Country:US
Practice Address - Phone:410-672-2862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW10713171M00000X
FLSW 107131041C0700X
MD211311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW10713OtherLCSW LICENSE
MD21131OtherSOCIAL WORK LICENSE