Basic Information
| Provider Information | |||||||||
| NPI: | 1518224419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | RENZY | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 948 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481840948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862228403 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1431 COLLIER STREET | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
| FaxNumber: | 5127031394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2012 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802085802 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 382753046 | 05 | MI | MEDICAID |