Provider Demographics
NPI:1811387970
Name:DAVIS, PHYLLIS (RAC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 NORTH WEADOCK
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607
Mailing Address - Country:US
Mailing Address - Phone:989-754-8598
Mailing Address - Fax:989-754-5154
Practice Address - Street 1:128 NORTH WEADOCK
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48607
Practice Address - Country:US
Practice Address - Phone:989-754-8598
Practice Address - Fax:989-754-5154
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMCBAP DEVPMENT PLAN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)