Provider Demographics
NPI:1003291626
Name:DAVIDSON, KAREN MARISA
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARISA
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PARIS AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-1659
Mailing Address - Country:US
Mailing Address - Phone:203-376-4982
Mailing Address - Fax:
Practice Address - Street 1:345 GREENWOOD ST STE A
Practice Address - Street 2:SUITE B
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1767
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT92813207222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist