Provider Demographics
NPI:1427159631
Name:DAVIS, VICKY J (PHD, CAAC, CCJS)
Entity type:Individual
Prefix:DR
First Name:VICKY
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD, CAAC, CCJS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 LAKE GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48370-2003
Mailing Address - Country:US
Mailing Address - Phone:248-601-9990
Mailing Address - Fax:248-601-9991
Practice Address - Street 1:1460 WALTON BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1779
Practice Address - Country:US
Practice Address - Phone:248-601-9990
Practice Address - Fax:248-601-9991
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007985103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M86080Medicare PIN