Provider Demographics
NPI:1417462136
Name:DAVIDSON, MARIE (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:KIRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC, LAT
Mailing Address - Street 1:3100 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-3722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-3722
Practice Address - Country:US
Practice Address - Phone:863-370-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL40212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer