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General NPI Number Information
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NPI Number | 1023462728
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Entity Type | Individual
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Provider Name | ETHAN DAVIS LCSW
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Gender | Male
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Dates
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Enumeration Date | 04/19/2016
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Last Update Date | 11/23/2021
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Provider Practice Location Address
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Address Line | 300 HARDING BLVD STE 108
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City | ROSEVILLE
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State | CA
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Zip | 95678-2471
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Country | US
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Telephone | 916-741-0884
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2201
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City | ROCKLIN
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State | CA
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Zip | 95677-8201
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Country | US
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Telephone | 916-220-6784
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 102727
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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