Provider Demographics
NPI:1255434593
Name:DAVIDSON, ANSEL FABIAN (ADDICTION THERAPIST)
Entity type:Individual
Prefix:MR
First Name:ANSEL
Middle Name:FABIAN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:ADDICTION THERAPIST
Other - Prefix:MR
Other - First Name:ANSEL
Other - Middle Name:FABIAN
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ADDICTION THERAPIST
Mailing Address - Street 1:5791 BALFOUR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224
Mailing Address - Country:US
Mailing Address - Phone:313-576-1000
Mailing Address - Fax:313-576-1091
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:313-576-1091
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)