Provider Demographics
NPI:1760664965
Name:DAVIS, CONSTANCE ALICE (MFCC)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:ALICE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MFCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 WESTWOOD PL
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1548
Mailing Address - Country:US
Mailing Address - Phone:909-622-9966
Mailing Address - Fax:
Practice Address - Street 1:934 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3659
Practice Address - Country:US
Practice Address - Phone:909-579-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6236106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist