Basic Information
| Provider Information | |||||||||
| NPI: | 1750632485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | MAY | ||||||||
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| Credential: | C058110618 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16536 BALLINGER ST | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913431806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188004128 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14515 HAMLIN ST # 100 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182851900 | ||||||||
| FaxNumber: | 8182851906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 225400000X | C058110618 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.