Provider Demographics
NPI:1861898025
Name:DAVIS, MARC DARRELL
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:DARRELL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92581-0281
Mailing Address - Country:US
Mailing Address - Phone:951-634-0297
Mailing Address - Fax:
Practice Address - Street 1:1827 ATLANTA AVE
Practice Address - Street 2:SUITE D3
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7419
Practice Address - Country:US
Practice Address - Phone:951-955-8000
Practice Address - Fax:951-955-8010
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health