Provider Demographics
NPI:1114630787
Name:DAVIS, EBONY LAQUISE (RADT)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:LAQUISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 NORTHCREST CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1064
Mailing Address - Country:US
Mailing Address - Phone:330-774-3717
Mailing Address - Fax:
Practice Address - Street 1:4441 AUBURN BLVD STE E
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-4139
Practice Address - Country:US
Practice Address - Phone:916-473-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)