Provider Demographics
NPI:1033656913
Name:DAVIS, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5242 PLAINFIELD AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1084
Mailing Address - Country:US
Mailing Address - Phone:616-363-2200
Mailing Address - Fax:616-363-5337
Practice Address - Street 1:5242 PLAINFIELD AVE NE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-363-2200
Practice Address - Fax:616-363-5337
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
MI7401000675103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0-16-7571OtherBCABA