Healthcare Provider Details

I. General information

NPI: 1740803659
Provider Name (Legal Business Name): MISS ALYSE RENEE DAVIDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 LANGSDORF DR STE 200
FULLERTON CA
92831-3702
US

IV. Provider business mailing address

7803 PRIMROSE DR
BUENA PARK CA
90620-2135
US

V. Phone/Fax

Practice location:
  • Phone: 714-871-9264
  • Fax:
Mailing address:
  • Phone: 714-234-6136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number142957
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: