MEDICARE: MS. THERESE J DAVIS LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LMFT47466	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10200	OTHER	CA	UBH PROVIDER STAFF ID

General Provider Information

NPI Number	:	1538290580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESE J DAVIS LMFT

Provider Business Mailing Address
First Line	:	4411 30TH ST
Second Line	:	SUITE 101
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-4286
Country	:	US
Telephone Number	:	858-663-7620
Fax Number	:

Provider Business Practice Location Address
First Line	:	4411 30TH ST
Second Line	:	SUITE 101
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-4286
Country	:	US
Telephone Number	:	858-663-7620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	05/03/2016

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