Provider Demographics
NPI:1114977121
Name:DAVIDSON, CARLA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:MARIE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:CARLA
Other - Middle Name:MARIE
Other - Last Name:LUCERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1249 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2518
Mailing Address - Country:US
Mailing Address - Phone:909-981-9989
Mailing Address - Fax:
Practice Address - Street 1:8253 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-987-1997
Practice Address - Fax:909-987-0993
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20719OtherPROFESSIONAL LICENSE