Healthcare Provider Details

I. General information

NPI: 1073719480
Provider Name (Legal Business Name): CLAYTIE DAVIS III PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT WAY
BERKELEY CA
94720-4304
US

IV. Provider business mailing address

2222 BANCROFT WAY
BERKELEY CA
94720-4304
US

V. Phone/Fax

Practice location:
  • Phone: 510-642-9336
  • Fax: 510-642-2368
Mailing address:
  • Phone: 510-642-9336
  • Fax: 510-642-2368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY 17206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: