Provider Demographics
NPI:1619333655
Name:DAVIDSON, BROOKE LAUREN (LCSW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAUREN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 SOUTH ST APT C
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1478
Mailing Address - Country:US
Mailing Address - Phone:914-261-4122
Mailing Address - Fax:
Practice Address - Street 1:1912 SOUTH ST APT C
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1478
Practice Address - Country:US
Practice Address - Phone:914-261-4122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW133070103K00000X
PACW0202641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst