Provider Demographics
NPI:1376692269
Name:DAVIS, GROVER WAYNE (BA,CSAC,CAC)
Entity Type:Individual
Prefix:
First Name:GROVER
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:BA,CSAC,CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 3RD ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-1976
Mailing Address - Country:US
Mailing Address - Phone:231-726-4735
Mailing Address - Fax:231-722-0789
Practice Address - Street 1:5816 W US HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2494
Practice Address - Country:US
Practice Address - Phone:231-843-4899
Practice Address - Fax:231-843-8929
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1712452Medicaid
MI20351Medicare UPIN
MIOP22320Medicare ID - Type Unspecified
MI1712452Medicaid
MI20378Medicare UPIN
MI20366Medicare UPIN