Provider Demographics
NPI:1114566619
Name:DAVIS, VICTORIA GLADYS
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:GLADYS
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 1:31611 HIPSHOT DR
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-2522
Mailing Address - Country:US
Mailing Address - Phone:213-999-6917
Mailing Address - Fax:
Practice Address - Street 1:28494 WESTINGHOUSE PL STE 213
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-0934
Practice Address - Country:US
Practice Address - Phone:661-259-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110476106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist