Provider Demographics
NPI:1396217212
Name:SABO, DAVIS BRIAN
Entity Type:Individual
Prefix:
First Name:DAVIS
Middle Name:BRIAN
Last Name:SABO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21126 MICHAEL CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3068
Mailing Address - Country:US
Mailing Address - Phone:313-320-6318
Mailing Address - Fax:
Practice Address - Street 1:26001 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2309
Practice Address - Country:US
Practice Address - Phone:586-779-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005673225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508053661Medicaid