Provider Demographics
NPI:1073735080
Name:DAVIS, MIRIAM (MFT)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 WEST ALAMEDA AVENUE
Mailing Address - Street 2:SUITE 514
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-848-3022
Mailing Address - Fax:818-895-6936
Practice Address - Street 1:2625 WEST ALAMEDA AVENUE
Practice Address - Street 2:SUITE 514
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-848-3022
Practice Address - Fax:818-895-6936
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31571106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ44196ZOtherBLUE SHIELD BLUE CARD