MEDICARE: DR. KENNETH DUFF DAVIS PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	33457	CA

General Provider Information

NPI Number	:	1245965854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH DUFF DAVIS PHD

Provider Business Mailing Address
First Line	:	16162 BEACH BLVD STE 308
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3894
Country	:	US
Telephone Number	:	714-596-0959
Fax Number	:

Provider Business Practice Location Address
First Line	:	16162 BEACH BLVD STE 308
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3894
Country	:	US
Telephone Number	:	714-596-0959
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2022
Last Update Date	:	07/18/2022

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