Provider Demographics
NPI:1922750850
Name:DAVIS, CAROL ANN LUCY (PSYD, DRPH)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN LUCY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD, DRPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22130 LADERA ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-6016
Mailing Address - Country:US
Mailing Address - Phone:909-838-5590
Mailing Address - Fax:
Practice Address - Street 1:22130 LADERA ST
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-6016
Practice Address - Country:US
Practice Address - Phone:909-838-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28828103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist