Provider Demographics
NPI:1972009462
Name:DAVIDSON, MARIA LASALLE (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:LASALLE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9718 HEATH AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-5518
Mailing Address - Country:US
Mailing Address - Phone:216-404-9506
Mailing Address - Fax:
Practice Address - Street 1:11811 SHAKER BLVD STE 113A
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1927
Practice Address - Country:US
Practice Address - Phone:216-509-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI1500352101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health