Provider Demographics
NPI:1144801010
Name:DAVIS, IME
Entity Type:Individual
Prefix:
First Name:IME
Middle Name:
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:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90714-1026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2271 ALPINE BLVD STE A
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1101
Practice Address - Country:US
Practice Address - Phone:619-448-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117473106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist