Healthcare Provider Details

I. General information

NPI: 1639589757
Provider Name (Legal Business Name): DAVID LEE MASTERS CADC & ICADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RIVER AVE
DETROIT MI
48204-2139
US

IV. Provider business mailing address

9605 GRAND RIVER AVE
DETROIT MI
48204-2139
US

V. Phone/Fax

Practice location:
  • Phone: 313-834-5930
  • Fax:
Mailing address:
  • Phone: 313-834-5930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: