Healthcare Provider Details

I. General information

NPI: 1114630787
Provider Name (Legal Business Name): EBONY LAQUISE DAVIS RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 AUBURN BLVD STE E
SACRAMENTO CA
95841-4139
US

IV. Provider business mailing address

1820 J ST
SACRAMENTO CA
95811-3010
US

V. Phone/Fax

Practice location:
  • Phone: 916-473-5764
  • Fax:
Mailing address:
  • Phone: 330-774-3717
  • Fax: 916-822-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA066740725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: