Provider Demographics
NPI:1740803659
Name:DAVIDSON, ALYSE RENEE
Entity Type:Individual
Prefix:MISS
First Name:ALYSE
Middle Name:RENEE
Last Name:DAVIDSON
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 1:7803 PRIMROSE DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2135
Mailing Address - Country:US
Mailing Address - Phone:714-234-6136
Mailing Address - Fax:
Practice Address - Street 1:680 LANGSDORF DR STE 200
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3702
Practice Address - Country:US
Practice Address - Phone:714-871-9264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142957106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist