Provider Demographics
NPI:1184083115
Name:DAVIDSON, DAVID W
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
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 1:5502 VINTAGE CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2510
Mailing Address - Country:US
Mailing Address - Phone:209-898-1615
Mailing Address - Fax:
Practice Address - Street 1:2431 W MARCH LN
Practice Address - Street 2:SUITE 210
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8211
Practice Address - Country:US
Practice Address - Phone:209-898-9859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT91243106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist