Provider Demographics
NPI:1063273233
Name:DAVIS, DEDRICK XAVIER
Entity type:Individual
Prefix:
First Name:DEDRICK
Middle Name:XAVIER
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 1:2020 N VINE CIR
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-8937
Mailing Address - Country:US
Mailing Address - Phone:559-670-8789
Mailing Address - Fax:
Practice Address - Street 1:2020 N VINE CIR
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-8937
Practice Address - Country:US
Practice Address - Phone:559-670-8789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
CA2345634103TA0400X
CA103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)