Provider Demographics
NPI:1285687889
Name:DAVIDSON, CHARME S (PHD, ABPP)
Entity Type:Individual
Prefix:
First Name:CHARME
Middle Name:S
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1846
Mailing Address - Country:US
Mailing Address - Phone:612-825-2868
Mailing Address - Fax:612-870-4542
Practice Address - Street 1:1409 WILLOW ST
Practice Address - Street 2:SUITE 220
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2269
Practice Address - Country:US
Practice Address - Phone:612-870-0510
Practice Address - Fax:612-870-4542
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2642103T00000X
MNMFT0245106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6275478000Medicaid
MNLP2642OtherMN PSYCHOLOGY LICENSE #
MN0245OtherMN MARRIAGE & FAM LIC #
MN3962OtherABPP #