Provider Demographics
NPI:1598997678
Name:DAVIS, KATHRYN MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:MARIE
Other - Last Name:PAVLIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:250 S G ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3320
Mailing Address - Country:US
Mailing Address - Phone:909-382-7100
Mailing Address - Fax:909-382-7101
Practice Address - Street 1:250 S G ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3320
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25988103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program