Provider Demographics
NPI:1336545185
Name:DAVIS, LISA M (CAC-AD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8930 STANFORD BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045
Mailing Address - Country:US
Mailing Address - Phone:410-313-6202
Mailing Address - Fax:410-313-6212
Practice Address - Street 1:7121 COLUMBIA GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046
Practice Address - Country:US
Practice Address - Phone:410-872-8753
Practice Address - Fax:410-313-6212
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0735101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)