Provider Demographics
NPI:1457386823
Name:DAVIDSON, SCOTT J (EDD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-0871
Mailing Address - Country:US
Mailing Address - Phone:207-751-5429
Mailing Address - Fax:
Practice Address - Street 1:9 EVERETT ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2403
Practice Address - Country:US
Practice Address - Phone:207-751-5429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPSYCH000501103TC0700X
MEPS501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME135350000Medicaid
ME003544OtherANTHEM STAR #
ME5594271OtherAETNA
ME135350000Medicaid