Provider Demographics
NPI:1972371185
Name:DAVIS, SHATARA VIVIAN
Entity Type:Individual
Prefix:
First Name:SHATARA
Middle Name:VIVIAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22555 PALACE CT APT 101
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4576
Mailing Address - Country:US
Mailing Address - Phone:586-305-2432
Mailing Address - Fax:
Practice Address - Street 1:24600 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2471
Practice Address - Country:US
Practice Address - Phone:586-305-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator