Provider Demographics
NPI:1629418710
Name:DAVIS, REDD EDEEJAHNAI
Entity Type:Individual
Prefix:
First Name:REDD
Middle Name:EDEEJAHNAI
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 281
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92581-0281
Mailing Address - Country:US
Mailing Address - Phone:951-880-5597
Mailing Address - Fax:
Practice Address - Street 1:3095 CHRISTIANNE CIR
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-1592
Practice Address - Country:US
Practice Address - Phone:951-880-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW63685101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health