Basic Information
| Provider Information | |||||||||
| NPI: | 1427647585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2066 N SHORE DR SE APT 202 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495080930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163401892 | ||||||||
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| Practice Location | |||||||||
| Address1: | 360 E. BETLINE NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2021 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 680108752 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.