Basic Information
| Provider Information | |||||||||
| NPI: | 1861898025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | DARRELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 281 | ||||||||
| Address2: | |||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925810281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516340297 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1827 ATLANTA AVE | ||||||||
| Address2: | SUITE D3 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925077419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519558000 | ||||||||
| FaxNumber: | 9519558010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2014 | ||||||||
| LastUpdateDate: | 11/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.