Provider Demographics
NPI:1013479708
Name:DAVIDSON, AMANDA JEANNE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEANNE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-6001
Mailing Address - Country:US
Mailing Address - Phone:781-990-9090
Mailing Address - Fax:
Practice Address - Street 1:23 DUNCAN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-6001
Practice Address - Country:US
Practice Address - Phone:781-990-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone