Basic Information
| Provider Information | |||||||||
| NPI: | 1972617090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | AAS CAC-1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1356 HIGHNOON DRIVE | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | ONTARIO | ||||||||
| PostalCode: | N9G2X2 | ||||||||
| CountryCode: | CA | ||||||||
| TelephoneNumber: | 5199725575 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | 3135761091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 101YA0400X | MI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.