Provider Demographics
NPI:1780225250
Name:DAVIS, MARK N (MA LEP NCSP ABSNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:N
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MA LEP NCSP ABSNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1538
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95927-1538
Mailing Address - Country:US
Mailing Address - Phone:530-570-6822
Mailing Address - Fax:
Practice Address - Street 1:1479 OAK RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-8856
Practice Address - Country:US
Practice Address - Phone:530-570-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3468103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty