Provider Demographics
NPI:1497257349
Name:D'AVANZO, DEVON
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:D'AVANZO
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 1:13925 SAN PABLO AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3676
Mailing Address - Country:US
Mailing Address - Phone:415-456-7724
Mailing Address - Fax:
Practice Address - Street 1:1810 HOPKINS ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2717
Practice Address - Country:US
Practice Address - Phone:416-617-9806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT110602106H00000X
RBT-17-32057106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician