Provider Demographics
NPI: | 1942962717 |
---|---|
Name: | DAVIS, SANETRIA |
Entity Type: | Individual |
Prefix: | |
First Name: | SANETRIA |
Middle Name: | |
Last Name: | DAVIS |
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: | 1221 BLUEBONNET DR |
Mailing Address - Street 2: | |
Mailing Address - City: | DESOTO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75115-6682 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 214-206-7779 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1221 BLUEBONNET DR |
Practice Address - Street 2: | |
Practice Address - City: | DESOTO |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75115-6682 |
Practice Address - Country: | US |
Practice Address - Phone: | 214-206-7779 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2021-10-09 |
Last Update Date: | 2021-10-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 66355 | 261QM0850X, 261QM0801X, 261QM0855X, 101YM0800X, 171M00000X, 251B00000X, 251S00000X, 3104A0625X, 310500000X, 320800000X, 322D00000X, 323P00000X, 324500000X, 1041C0700X |
3104A0625X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | |
No | 251B00000X | Agencies | Case Management | |
No | 251S00000X | Agencies | Community/Behavioral Health | |
No | 310500000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness | |
No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | |
No | 322D00000X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | |
No | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | |
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |