Provider Demographics
NPI:1073525895
Name:DAVIS, MIKOL S (EDD)
Entity Type:Individual
Prefix:
First Name:MIKOL
Middle Name:S
Last Name:DAVIS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
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:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9063103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAED889ZMedicare UPIN
CAED890AMedicare UPIN