Healthcare Provider Details

I. General information

NPI: 1518589662
Provider Name (Legal Business Name): CAROL LYNN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

7200 BANCROFT AVE STE 133
OAKLAND CA
94605-2480
US

IV. Provider business mailing address

2308 SAINT GEORGE DR
CONCORD CA
94520-1331
US

V. Phone/Fax

Practice location:
  • Phone: 510-553-8500
  • Fax:
Mailing address:
  • Phone: 925-876-0195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number37421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: