Provider Demographics
NPI:1225174030
Name:DAVIS, CAROL LOUISE (RN, LCSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LOUISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E VANDERBILT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0928
Mailing Address - Country:US
Mailing Address - Phone:909-386-8207
Mailing Address - Fax:
Practice Address - Street 1:303 E VANDERBILT WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0928
Practice Address - Country:US
Practice Address - Phone:909-386-8207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS234511041C0700X
CA396826163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical