Healthcare Provider Details

I. General information

NPI: 1831226349
Provider Name (Legal Business Name): OLUWA REGINALD DAVIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15819 SCHOOLCRAFT ST
DETROIT MI
48227-1749
US

IV. Provider business mailing address

15819 SCHOOLCRAFT ST
DETROIT MI
48227-1749
US

V. Phone/Fax

Practice location:
  • Phone: 313-493-4900
  • Fax: 313-493-4904
Mailing address:
  • Phone: 313-493-4900
  • Fax: 313-493-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberL963529
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: