Provider Demographics
NPI:1033412853
Name:DR. MIKOL S. DAVIS, CHILD & FAMILY COUNSELING, A PROFESSIONAL CORPORAT
Entity Type:Organization
Organization Name:DR. MIKOL S. DAVIS, CHILD & FAMILY COUNSELING, A PROFESSIONAL CORPORAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKOL
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:415-459-1203
Mailing Address - Street 1:930 IRWIN ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3340
Mailing Address - Country:US
Mailing Address - Phone:415-459-1203
Mailing Address - Fax:415-459-3682
Practice Address - Street 1:930 IRWIN ST
Practice Address - Street 2:SUITE 215
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3340
Practice Address - Country:US
Practice Address - Phone:415-459-1203
Practice Address - Fax:415-459-3682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00PL90630103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAED890AMedicare PIN