Healthcare Provider Details

I. General information

NPI: 1578304010
Provider Name (Legal Business Name): TESSA ANN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

IV. Provider business mailing address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

V. Phone/Fax

Practice location:
  • Phone: 734-718-4947
  • Fax:
Mailing address:
  • Phone: 734-718-4947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851118435
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: