Provider Demographics
NPI:1306181292
Name:DAVIS, JULIA ALICE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:ALICE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:JULIA
Other - Middle Name:
Other - Last Name:MOBASSALEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:414 S MAIN ST STE 208C
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2070
Mailing Address - Country:US
Mailing Address - Phone:248-764-5550
Mailing Address - Fax:248-287-4123
Practice Address - Street 1:414 S MAIN ST STE 208C
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2070
Practice Address - Country:US
Practice Address - Phone:248-764-5550
Practice Address - Fax:248-287-4123
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91207106H00000X
MI4101006762106H00000X, 106H00000X
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI82-2993698OtherTAX IDENTIFICATION NUMBER TIN