Provider Demographics
NPI:1659641835
Name:DAVIS, DEATRIA
Entity Type:Individual
Prefix:MRS
First Name:DEATRIA
Middle Name:
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 1:231 GEE GEE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3278
Mailing Address - Country:US
Mailing Address - Phone:209-752-1965
Mailing Address - Fax:
Practice Address - Street 1:2600 S. EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403
Practice Address - Country:US
Practice Address - Phone:209-752-1965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program