Provider Demographics
NPI:1326798604
Name:DAVIS, MARVIN LEE JR (BS)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:LEE
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9412 BIG HORN BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-1101
Mailing Address - Country:US
Mailing Address - Phone:916-396-4906
Mailing Address - Fax:
Practice Address - Street 1:9412 BIG HORN BLVD STE 6
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-1101
Practice Address - Country:US
Practice Address - Phone:916-396-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor