Provider Demographics
NPI:1679850713
Name:DAVIS, KRYSTAL MASON (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:MASON
Last Name:DAVIS
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 1:10 PETERBORO
Mailing Address - Street 2:3RD FLOOR HOUSING
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-833-6685
Mailing Address - Fax:313-833-4624
Practice Address - Street 1:10 PETERBORO
Practice Address - Street 2:3RD FLOOR HOUSING
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-833-6685
Practice Address - Fax:313-833-4624
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010930241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical