MEDICARE: MRS. DOLORES MARIA 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	225800000X	Recreation Therapist
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1629138680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DOLORES MARIA DAVIS

Provider Business Mailing Address
First Line	:	83 E SHAW AVE
Second Line	:	102
City	:	FRESNO
State	:	CA
Zip	:	93710-7620
Country	:	US
Telephone Number	:	559-226-0167
Fax Number	:	559-226-1559

Provider Business Practice Location Address
First Line	:	83 E SHAW AVE
Second Line	:	102
City	:	FRESNO
State	:	CA
Zip	:	93710-7620
Country	:	US
Telephone Number	:	559-226-0167
Fax Number	:	559-226-1559

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	01/03/2011

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