Provider Demographics
NPI:1396915567
Name:DAVIS, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
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 1:3277 PRENTISS ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2614
Mailing Address - Country:US
Mailing Address - Phone:510-289-6443
Mailing Address - Fax:
Practice Address - Street 1:16378 E 14TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-5121
Practice Address - Country:US
Practice Address - Phone:510-667-3285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114687106H00000X
101YA0400X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)