Provider Demographics
NPI:1053439737
Name:DAVIS, GERALDINE ETELLA (BS)
Entity type:Individual
Prefix:MS
First Name:GERALDINE
Middle Name:ETELLA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2047 CHARLTON ST APT 101
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3953
Mailing Address - Country:US
Mailing Address - Phone:734-997-9214
Mailing Address - Fax:
Practice Address - Street 1:3840 FAIRVIEW ST.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214
Practice Address - Country:US
Practice Address - Phone:313-331-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3022440Medicaid
MI1063545556OtherGENESIS HOUSE III