Healthcare Provider Details

I. General information

NPI: 1902200454
Provider Name (Legal Business Name): DAVID SCOTT BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RIVER AVE
DETROIT MI
48204-2139
US

IV. Provider business mailing address

7479 TROUTWOOD DR APT 1B
GRAND BLANC MI
48439-7507
US

V. Phone/Fax

Practice location:
  • Phone: 313-834-5930
  • Fax:
Mailing address:
  • Phone: 810-620-4780
  • 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: