Provider Demographics
NPI:1164813796
Name:DAVIS, REBECCA MAEJEAN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MAEJEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4926
Mailing Address - Country:US
Mailing Address - Phone:600-295-1654
Mailing Address - Fax:951-602-8195
Practice Address - Street 1:790 S STATE ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4926
Practice Address - Country:US
Practice Address - Phone:600-295-1654
Practice Address - Fax:951-602-8195
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA135557106H00000X
CA103158106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist