Provider Demographics
NPI:1508374091
Name:DAVIS, VENETTA EVON
Entity Type:Individual
Prefix:
First Name:VENETTA
Middle Name:EVON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VENETTA
Other - Middle Name:EVON
Other - Last Name:DAVIS DEL CASTILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11041 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2516
Mailing Address - Country:US
Mailing Address - Phone:626-442-4177
Mailing Address - Fax:
Practice Address - Street 1:11041 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2516
Practice Address - Country:US
Practice Address - Phone:626-442-4177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA205684101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)