Provider Demographics
NPI:1568682912
Name:DAVIDSON, WAYNE EDWARD (LMHC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:EDWARD
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14921 W HARDY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1546
Mailing Address - Country:US
Mailing Address - Phone:813-979-0535
Mailing Address - Fax:813-975-9769
Practice Address - Street 1:14437 UNIVERSITY COVE PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3741
Practice Address - Country:US
Practice Address - Phone:813-979-0535
Practice Address - Fax:813-975-9769
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4879101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001296600Medicaid