Provider Demographics
NPI:1790128494
Name:DAVIDOVICH, ILYA V (LMSW)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:V
Last Name:DAVIDOVICH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 S IVANHOE AVE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7113
Mailing Address - Country:US
Mailing Address - Phone:734-484-9834
Mailing Address - Fax:
Practice Address - Street 1:1001 S RAISINVILLE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9754
Practice Address - Country:US
Practice Address - Phone:734-384-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010875581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical