Healthcare Provider Details

I. General information

NPI: 1457486904
Provider Name (Legal Business Name): SALLY DAVIS YEATMAN L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

IV. Provider business mailing address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8701
  • Fax:
Mailing address:
  • Phone: 310-829-8701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS17239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: