Provider Demographics
NPI:1023497096
Name:DAVIDSON, MICHELLE ANGELIQUE (MSED)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ANGELIQUE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3640
Mailing Address - Country:US
Mailing Address - Phone:646-275-4500
Mailing Address - Fax:
Practice Address - Street 1:2134 E 22ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3640
Practice Address - Country:US
Practice Address - Phone:646-275-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-24
Last Update Date:2015-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1144774252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency