Provider Demographics
NPI:1447753702
Name:DAVIDSON, COREY GLEN
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:GLEN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11018 NE 98TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-2274
Mailing Address - Country:US
Mailing Address - Phone:360-213-9405
Mailing Address - Fax:
Practice Address - Street 1:100 E 13TH ST STE 111
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3329
Practice Address - Country:US
Practice Address - Phone:360-521-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60656485225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist