Provider Demographics
NPI:1598789026
Name:DAVIS, KENNETH WILLIAM (MFT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 11TH ST
Mailing Address - Street 2:SUITE 11 H
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2308
Mailing Address - Country:US
Mailing Address - Phone:209-521-7526
Mailing Address - Fax:209-521-7530
Practice Address - Street 1:948 11TH ST
Practice Address - Street 2:SUITE 11 H
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2308
Practice Address - Country:US
Practice Address - Phone:209-521-7526
Practice Address - Fax:209-521-7530
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 18277106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist