Provider Demographics
NPI:1932230562
Name:DAVIS, BOBBY JEROME (LCSW 24919)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:JEROME
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LCSW 24919
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 WOOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1434
Mailing Address - Country:US
Mailing Address - Phone:818-568-9029
Mailing Address - Fax:
Practice Address - Street 1:4240 W 62ND ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-3615
Practice Address - Country:US
Practice Address - Phone:323-299-0369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 249191041C0700X
CA249191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01605808Medicare UPIN