Healthcare Provider Details

I. General information

NPI: 1467330837
Provider Name (Legal Business Name): NICOLE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3239 GIDDINGS AVE SE
GRAND RAPIDS MI
49508-2578
US

IV. Provider business mailing address

3239 GIDDINGS AVE SE
GRAND RAPIDS MI
49508-2578
US

V. Phone/Fax

Practice location:
  • Phone: 616-548-1166
  • Fax:
Mailing address:
  • Phone: 616-548-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6401225318
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: