Provider Demographics
NPI:1972986958
Name:DAVIDSON, ANDREW C
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W ARCH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-1319
Mailing Address - Country:US
Mailing Address - Phone:260-251-0947
Mailing Address - Fax:
Practice Address - Street 1:610 W ARCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1319
Practice Address - Country:US
Practice Address - Phone:260-251-0947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health