Provider Demographics
NPI:1497005508
Name:DAVIS, DANIEL ALLEN (MA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ALLEN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:A
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:54251 OLD MILL DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-4819
Mailing Address - Country:US
Mailing Address - Phone:517-599-0085
Mailing Address - Fax:
Practice Address - Street 1:519 S PARK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5117
Practice Address - Country:US
Practice Address - Phone:269-383-2294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013106101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497005508OtherBEHAVIORAL HEALTH & SOCIAL SERVICES PROVIDER