Provider Demographics
NPI:1558776104
Name:DAVIS, MARTHA ANN (LPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:800-395-3223
Mailing Address - Fax:
Practice Address - Street 1:3744 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1802
Practice Address - Country:US
Practice Address - Phone:616-466-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014279101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional