Provider Demographics
NPI:1154834158
Name:DAVIS, MICHELLE RENEE (LPCC-S)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:MATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC-S
Mailing Address - Street 1:37303 HARVEST AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-2803
Mailing Address - Country:US
Mailing Address - Phone:440-847-8505
Mailing Address - Fax:
Practice Address - Street 1:519 NEWHAVEN ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:CA
Practice Address - Zip Code:91377-4821
Practice Address - Country:US
Practice Address - Phone:216-409-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2102428-SUPV101YP2500X
IL180.015142101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0286648Medicaid