MEDICARE: VICKI DAVISON LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist		MI
2	103TC1900X	Counseling Psychologist	6301013957	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6301013957	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1083133607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKI DAVISON LLP

Provider Business Mailing Address
First Line	:	450 4TH AVE
Second Line	:
City	:	LAKE ODESSA
State	:	MI
Zip	:	48849-1204
Country	:	US
Telephone Number	:	616-460-6848
Fax Number	:	616-676-4253

Provider Business Practice Location Address
First Line	:	1040 4TH AVE
Second Line	:
City	:	LAKE ODESSA
State	:	MI
Zip	:	48849-1004
Country	:	US
Telephone Number	:	616-460-6848
Fax Number	:	616-676-4253

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2017
Last Update Date	:	09/14/2017

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Directions to “ VICKI DAVISON LLP” Practice Location

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