Provider Demographics
NPI:1851912604
Name:DAVIS, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MAYFIELD RD APT 8
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1752
Mailing Address - Country:US
Mailing Address - Phone:256-577-3838
Mailing Address - Fax:
Practice Address - Street 1:635 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-5313
Practice Address - Country:US
Practice Address - Phone:256-764-3431
Practice Address - Fax:256-765-2036
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002418390200000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program