Provider Demographics
NPI:1588802789
Name:DAVIS, THERESA M (MFT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5913 BAR HARBOUR CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4230
Mailing Address - Country:US
Mailing Address - Phone:916-985-7212
Mailing Address - Fax:916-985-7212
Practice Address - Street 1:310 NATOMA ST # 140
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-2620
Practice Address - Country:US
Practice Address - Phone:916-985-7212
Practice Address - Fax:916-985-7212
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 38963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist