Provider Demographics
NPI:1679602783
Name:DAVIDSON, MICHELLE LATONDRA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LATONDRA
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 1:10401 LINN STATION RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3842
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:502-589-8745
Practice Address - Street 1:600 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1716
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100284300Medicaid
KY61-0471572Medicaid
KY1033275342Medicaid
KY1740554864Medicaid
KY1265598270Medicaid
KY1477618718Medicaid