Provider Demographics
NPI:1972115293
Name:DAVIS, NICOLE (PSYD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:419 WATERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8052
Mailing Address - Country:US
Mailing Address - Phone:213-840-1389
Mailing Address - Fax:
Practice Address - Street 1:128 SIERRA ST STE C
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4117
Practice Address - Country:US
Practice Address - Phone:310-989-1971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94026437101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health