MEDICARE: MS. DAVISON SARAI NICHOLAS LPC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	6401012436	MI
2	101YP2500X	Professional Counselor	6401019337	MI

General Provider Information

NPI Number	:	1114273653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DAVISON SARAI NICHOLAS LPC

Provider Business Mailing Address
First Line	:	1116 JACKSON STREET
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49001
Country	:	US
Telephone Number	:	269-215-1454
Fax Number	:

Provider Business Practice Location Address
First Line	:	4370 CHICAGO DR SW
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1694
Country	:	US
Telephone Number	:	269-215-1454
Fax Number	:

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

Provider Enumeration Date	:	08/02/2012
Last Update Date	:	01/16/2024

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