Provider Demographics
NPI:1134942980
Name:DAVIS, CHARLES SAMUEL
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SAMUEL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 LAS ESTRELLAS CT
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-4070
Mailing Address - Country:US
Mailing Address - Phone:805-407-4533
Mailing Address - Fax:
Practice Address - Street 1:2009 LAS ESTRELLAS CT
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-4070
Practice Address - Country:US
Practice Address - Phone:805-407-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician