Provider Demographics
NPI:1821364001
Name:DAVIDSON, COLLIN (PHD)
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 WENTWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-4941
Mailing Address - Country:US
Mailing Address - Phone:405-612-3428
Mailing Address - Fax:
Practice Address - Street 1:1221 W LAKE ST STE 201
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3565
Practice Address - Country:US
Practice Address - Phone:303-399-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-01
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MNLP5748103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist