Provider Demographics
NPI:1780023630
Name:DAVAULT, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DAVAULT
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 1:6106 NAGLE AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-3018
Mailing Address - Country:US
Mailing Address - Phone:818-342-5897
Mailing Address - Fax:818-975-5008
Practice Address - Street 1:7101 BAIRD AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4150
Practice Address - Country:US
Practice Address - Phone:818-342-5897
Practice Address - Fax:818-975-5008
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93853106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist