Provider Demographics
NPI:1518589662
Name:DAVIS, CAROL LYNN
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:DAVIS
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 1:2308 SAINT GEORGE DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1331
Mailing Address - Country:US
Mailing Address - Phone:925-876-0195
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE STE 133
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2480
Practice Address - Country:US
Practice Address - Phone:510-553-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37421167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician