Provider Demographics
NPI:1447803002
Name:DAVIDSON, KOLTON
Entity Type:Individual
Prefix:
First Name:KOLTON
Middle Name:
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 1:1308 N LEONA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-4232
Mailing Address - Country:US
Mailing Address - Phone:920-730-1028
Mailing Address - Fax:
Practice Address - Street 1:3000 W SPENCER ST APT B18
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-4354
Practice Address - Country:US
Practice Address - Phone:920-540-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator