Provider Demographics
NPI:1891435343
Name:DAVIS, ANDREI VAUGHN (MSED)
Entity Type:Individual
Prefix:
First Name:ANDREI
Middle Name:VAUGHN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 WASHINGTON AVE APT 3B
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1359
Mailing Address - Country:US
Mailing Address - Phone:347-749-1087
Mailing Address - Fax:
Practice Address - Street 1:60 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3103
Practice Address - Country:US
Practice Address - Phone:518-265-3153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP112400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health