Provider Demographics
NPI:1013484773
Name:DAVIS, SHOSHANA ROSE (AMFT)
Entity Type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:ROSE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:AMFT
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 2743
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95473-2743
Mailing Address - Country:US
Mailing Address - Phone:707-696-9648
Mailing Address - Fax:
Practice Address - Street 1:7765 HEALDSBURG AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3309
Practice Address - Country:US
Practice Address - Phone:707-696-9648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT110154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist