Provider Demographics
NPI:1750632485
Name:DAVIS, DONNA MAY (C058110618)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MAY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:C058110618
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16536 BALLINGER ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91343-1806
Mailing Address - Country:US
Mailing Address - Phone:818-800-4128
Mailing Address - Fax:
Practice Address - Street 1:14515 HAMLIN ST # 100
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411
Practice Address - Country:US
Practice Address - Phone:818-285-1900
Practice Address - Fax:818-285-1906
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAC058110618225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)