Provider Demographics
NPI:1023775327
Name:DAVIS, THERESE CHRISTINE (CCM RN)
Entity type:Individual
Prefix:MS
First Name:THERESE
Middle Name:CHRISTINE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CCM RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5730
Mailing Address - Country:US
Mailing Address - Phone:410-724-2628
Mailing Address - Fax:410-505-2836
Practice Address - Street 1:1501 S CLINTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5730
Practice Address - Country:US
Practice Address - Phone:410-724-2628
Practice Address - Fax:410-505-2836
Is Sole Proprietor?:No
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN67877171M00000X
PATLRN060007171M00000X
CT175204171M00000X
DEL-0034049171M00000X
VT026.0143760171M00000X
MD4242289171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator