Provider Demographics
NPI:1851777494
Name:DAVIDSON, BROOKE WORTHINGTON (AUD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:WORTHINGTON
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ANNE
Other - Last Name:WORTHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:PO BOX 41516
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-1516
Mailing Address - Country:US
Mailing Address - Phone:904-202-5111
Mailing Address - Fax:904-391-5836
Practice Address - Street 1:1370 13TH AVE S STE 115
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-202-6390
Practice Address - Fax:904-390-7388
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1954231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIH877YMedicare UPIN
FLIH877ZMedicare UPIN