Provider Demographics
NPI:1962988964
Name:DAVIS, CAITLYN LEA
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:LEA
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 1:1025 ATLANTIC AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1188
Mailing Address - Country:US
Mailing Address - Phone:510-328-7176
Mailing Address - Fax:
Practice Address - Street 1:1021 SCANDIA AVE APT 25
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-2463
Practice Address - Country:US
Practice Address - Phone:805-258-3987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95859627DMedicaid