Healthcare Provider Details

I. General information

NPI: 1225252562
Provider Name (Legal Business Name): ELIZABETH C. DAVIS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19291 NORTHLINE ROAD
SOUTHGATE MI
48195
US

IV. Provider business mailing address

6118 MAPLEVIEW LN
YPSILANTI MI
48197-9479
US

V. Phone/Fax

Practice location:
  • Phone: 734-287-1500
  • Fax: 734-287-1660
Mailing address:
  • Phone: 734-395-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080263
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: