1508956525 NPI number — MS. BENETTA A DAVIS BA LBSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508956525 NPI number — MS. BENETTA A DAVIS BA LBSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
BENETTA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BA LBSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
BENETTA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA LBSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508956525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1669 SAVANNAH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUPERIOR TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48198-3681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-444-7591
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19401 NORTHLINE RD. BLGD. 5
Provider Second Line Business Practice Location Address:
THE GUIDANCE CENTER
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-785-7718
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6802082868 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)