Provider Demographics
NPI:1083133607
Name:DAVISON, VICKI (LLP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:DAVISON
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-1204
Mailing Address - Country:US
Mailing Address - Phone:616-460-6848
Mailing Address - Fax:616-676-4253
Practice Address - Street 1:1040 4TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1004
Practice Address - Country:US
Practice Address - Phone:616-460-6848
Practice Address - Fax:616-676-4253
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103TC1900X
MI6301013957103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301013957OtherLICENSE