Provider Demographics
NPI:1285853804
Name:DAVIS, JOHN M IV (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:DAVIS
Suffix:IV
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:895 MORAGA ROAD
Mailing Address - Street 2:SUITE #10
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-5046
Mailing Address - Country:US
Mailing Address - Phone:510-693-8439
Mailing Address - Fax:925-377-5345
Practice Address - Street 1:895 MORAGA RD
Practice Address - Street 2:SUITE #10
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-5094
Practice Address - Country:US
Practice Address - Phone:510-693-8439
Practice Address - Fax:925-377-5345
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 7189103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist