Provider Demographics
NPI:1598384968
Name:DAVIS, RENEE COLLEEN (MFT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:COLLEEN
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 1:5225 CANYON CREST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6301
Mailing Address - Country:US
Mailing Address - Phone:951-248-4058
Mailing Address - Fax:
Practice Address - Street 1:5225 CANYON CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6301
Practice Address - Country:US
Practice Address - Phone:951-248-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT45046106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist