Basic Information
| Provider Information | |||||||||
| NPI: | 1275060683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVALOS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LYNN IRENE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1235 MCHENRY AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953505370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182060360 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1235 MCHENRY AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953505370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182060360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2017 | ||||||||
| LastUpdateDate: | 05/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 96257 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.