Provider Demographics
NPI:1265975817
Name:DAVEN, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DAVEN
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 1:18545 BURBANK BLVD
Mailing Address - Street 2:#14
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5743 CORSA AVE
Practice Address - Street 2:#221
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-4027
Practice Address - Country:US
Practice Address - Phone:818-390-0415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT94885106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist