1720332596 NPI number — MR. MARVIN HENRY DAVIDSON LMSW

Table of content: MR. MARVIN HENRY DAVIDSON LMSW (NPI 1720332596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720332596 NPI number — MR. MARVIN HENRY DAVIDSON LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
MARVIN
Provider Middle Name:
HENRY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720332596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14250 MANHATTAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48237-1170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-548-1642
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16001 W 9 MILE RD
Provider Second Line Business Practice Location Address:
PROVIDENCE HOSPITAL
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-4818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-849-2096
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2012

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: 1041C0700X , with the licence number:  6801000454 , 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)





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