Provider Demographics
NPI:1407827728
Name:DAVIDSON, HAROLD JEAN (MS, LPC)
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:JEAN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:HAL
Other - Middle Name:
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:3338 REDBUD ST.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-883-3195
Mailing Address - Fax:
Practice Address - Street 1:1736 E. SUNSHINE
Practice Address - Street 2:SUITE 309
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-883-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCS000637101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498228105Medicaid