MEDICARE: DIANE DAVIS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	D0504101726	CA

General Provider Information

NPI Number	:	1336344555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE DAVIS

Provider Business Mailing Address
First Line	:	510 WOLLAM AVE
Second Line	:
City	:	BAY POINT
State	:	CA
Zip	:	94565-4364
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 WOLLAM AVE
Second Line	:
City	:	BAY POINT
State	:	CA
Zip	:	94565-4364
Country	:	US
Telephone Number	:	925-458-1978
Fax Number	:	925-458-8996

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

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	07/08/2007

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Directions to “ DIANE DAVIS ” Practice Location

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