Provider Demographics
NPI:1154867299
Name:DAVIS, DIANE TREVOLEDES (CMT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:TREVOLEDES
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 E ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3734
Mailing Address - Country:US
Mailing Address - Phone:707-268-8926
Mailing Address - Fax:
Practice Address - Street 1:2910 HARRIS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4811
Practice Address - Country:US
Practice Address - Phone:707-972-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68808225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist