Provider Demographics
NPI:1760938534
Name:DAVIS, MICHAEL ANTHONY I
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:DAVIS
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 E DATE ST APT 118
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-8227
Mailing Address - Country:US
Mailing Address - Phone:909-541-6505
Mailing Address - Fax:
Practice Address - Street 1:1652 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-2817
Practice Address - Country:US
Practice Address - Phone:909-693-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
CA16075101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)