Provider Demographics
NPI:1205175791
Name:DEVIVO, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DEVIVO
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 1:619 MILL ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-2270
Mailing Address - Country:US
Mailing Address - Phone:734-646-3792
Mailing Address - Fax:800-601-8027
Practice Address - Street 1:120 S MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1975
Practice Address - Country:US
Practice Address - Phone:248-390-5791
Practice Address - Fax:248-250-6455
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801046519101YA0400X, 101YP2500X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist