Healthcare Provider Details

I. General information

NPI: 1548671878
Provider Name (Legal Business Name): TRISTEN DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 PENINSULAR DR SE STE 230A404
GRAND RAPIDS MI
49546-2442
US

IV. Provider business mailing address

5030 CORPORATE EXCHANGE BLVD SE FL 2
GRAND RAPIDS MI
49512-5506
US

V. Phone/Fax

Practice location:
  • Phone: 616-315-1226
  • Fax:
Mailing address:
  • Phone: 616-315-1226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178018115
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401224084
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: