Healthcare Provider Details

I. General information

NPI: 1053439737
Provider Name (Legal Business Name): GERALDINE ETELLA DAVIS B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 FAIRVIEW ST.
DETROIT MI
48214
US

IV. Provider business mailing address

2047 CHARLTON ST APT 101
ANN ARBOR MI
48103-3953
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-8990
  • Fax:
Mailing address:
  • Phone: 734-997-9214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: