Provider Demographics
NPI:1568502201
Name:DAVIDSON, RENEE ANTOINETTE (LMSW)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ANTOINETTE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49455 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1559
Mailing Address - Country:US
Mailing Address - Phone:586-255-9332
Mailing Address - Fax:
Practice Address - Street 1:49455 SHELBY RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-1559
Practice Address - Country:US
Practice Address - Phone:586-255-9332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010896571041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical