Provider Demographics
NPI:1861624462
Name:DAVIS, LORI MARIE
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:MARIE
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 1:1160 N DUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4600
Mailing Address - Country:US
Mailing Address - Phone:707-303-3235
Mailing Address - Fax:707-526-8300
Practice Address - Street 1:1160 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4600
Practice Address - Country:US
Practice Address - Phone:707-303-3235
Practice Address - Fax:707-526-8300
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY29336103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health