Provider Demographics
NPI:1528550845
Name:DAVIS, DEANDRA MISHELLE
Entity Type:Individual
Prefix:
First Name:DEANDRA
Middle Name:MISHELLE
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:PO BOX 431262
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-9262
Mailing Address - Country:US
Mailing Address - Phone:323-455-8458
Mailing Address - Fax:
Practice Address - Street 1:4211 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5622
Practice Address - Country:US
Practice Address - Phone:323-515-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker