=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285233437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMITT MELVIN DAVIS JR. MA, LLPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2020
-----------------------------------------------------
Last Update Date | 10/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 MORRIS AVE STE 200
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49440-1154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-805-3660
-----------------------------------------------------
Fax | 616-805-3631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2140 VALLEY ST
-----------------------------------------------------
City | NORTON SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-1261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401016447
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------