Provider Demographics
NPI:1679060230
Name:DAVIS, WILLIAM ROBERT (RADT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ROBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5703
Mailing Address - Country:US
Mailing Address - Phone:530-271-1140
Mailing Address - Fax:
Practice Address - Street 1:159 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5703
Practice Address - Country:US
Practice Address - Phone:530-271-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1362390919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)