Provider Demographics
NPI:1073670113
Name:DAVIDGE, CHERYL J (LMSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:J
Last Name:DAVIDGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MARYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-4324
Mailing Address - Country:US
Mailing Address - Phone:248-541-3303
Mailing Address - Fax:
Practice Address - Street 1:424 W 5TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2545
Practice Address - Country:US
Practice Address - Phone:248-953-3034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010128261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P48790Medicare PIN