Basic Information
| Provider Information | |||||||||
| NPI: | 1285233437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | EMMITT | ||||||||
| MiddleName: | MELVIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MA, LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2140 VALLEY ST | ||||||||
| Address2: | |||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441261 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 316 MORRIS AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494401154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
| FaxNumber: | 6168053631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401016447 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.