Healthcare Provider Details

I. General information

NPI: 1891338919
Provider Name (Legal Business Name): SONJA MARIE DAVALOS CM60638711
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 S ANGELINE ST
SEATTLE WA
98118-1712
US

IV. Provider business mailing address

3808 S ANGELINE ST
SEATTLE WA
98118-1712
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4880
  • Fax:
Mailing address:
  • Phone: 206-461-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberCM60638711
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: