Provider Demographics
NPI:1750946497
Name:DAVIS, SERINA LENORRIS
Entity type:Individual
Prefix:
First Name:SERINA
Middle Name:LENORRIS
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 1:19900 BEACH BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-3762
Mailing Address - Country:US
Mailing Address - Phone:877-538-4133
Mailing Address - Fax:
Practice Address - Street 1:19900 BEACH BLVD STE H
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-3762
Practice Address - Country:US
Practice Address - Phone:877-538-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT102173101YM0800X
CALMFT123671101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7184OtherMEDI-CAL
CA7667OtherMEDI-CAL
CA7708OtherMEDI-CAL
CA7368OtherMEDI-CAL