Provider Demographics
NPI:1104495290
Name:DAVALOS, CESSLIE FABIOLA
Entity type:Individual
Prefix:
First Name:CESSLIE
Middle Name:FABIOLA
Last Name:DAVALOS
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 1:333 S BEAUDRY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1466
Mailing Address - Country:US
Mailing Address - Phone:213-241-3841
Mailing Address - Fax:
Practice Address - Street 1:333 S BEAUDRY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1466
Practice Address - Country:US
Practice Address - Phone:213-241-3841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW102812101YM0800X
1041C0700X, 225400000X
CA102812101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner