Provider Demographics
NPI:1407506769
Name:DAVISON, STEPHANIE (BCBA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DAVISON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6225 SMITH AVE STE 1001A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1141 W MAIN AVE STE 201
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1695
Practice Address - Country:US
Practice Address - Phone:920-338-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI526-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst