Provider Demographics
NPI:1013616150
Name:DAVIS, KENITRA MCCALL
Entity type:Individual
Prefix:
First Name:KENITRA
Middle Name:MCCALL
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11412 DECEMBER WAY APT 204
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-3626
Mailing Address - Country:US
Mailing Address - Phone:301-693-1415
Mailing Address - Fax:
Practice Address - Street 1:11921 BOURNEFIELD WAY # A-1
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7815
Practice Address - Country:US
Practice Address - Phone:301-578-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty