Provider Demographics
NPI:1285936278
Name:DAVIS, CRESTON (THERAPIST)
Entity type:Individual
Prefix:MR
First Name:CRESTON
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 CONGRESS ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2783
Mailing Address - Country:US
Mailing Address - Phone:619-288-6866
Mailing Address - Fax:
Practice Address - Street 1:2725 CONGRESS ST STE 1D
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2783
Practice Address - Country:US
Practice Address - Phone:619-288-6866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2025-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51024106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
87-4153810OtherTID