Provider Demographics
NPI:1700133410
Name:DAVIS, MICHELLE LEE (MSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 533
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-0533
Mailing Address - Country:US
Mailing Address - Phone:231-876-7234
Mailing Address - Fax:231-876-7234
Practice Address - Street 1:7985 MACKINAW TRL
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8111
Practice Address - Country:US
Practice Address - Phone:231-876-6200
Practice Address - Fax:231-876-6299
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010924821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238635Medicare Oscar/Certification