Provider Demographics
NPI:1578079323
Name:DAVISON, ANTHONY L SR (MA ED, CAGS)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:L
Last Name:DAVISON
Suffix:SR
Gender:M
Credentials:MA ED, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRAND CHAIN
Mailing Address - State:IL
Mailing Address - Zip Code:62941-3404
Mailing Address - Country:US
Mailing Address - Phone:618-634-9800
Mailing Address - Fax:618-634-9864
Practice Address - Street 1:251 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GRAND CHAIN
Practice Address - State:IL
Practice Address - Zip Code:62941-3404
Practice Address - Country:US
Practice Address - Phone:618-634-9800
Practice Address - Fax:618-634-9864
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1191856103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool