Provider Demographics
NPI:1649641622
Name:DAVIDSON, KAITLYN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
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 1:189 LABAUGH ROAD
Mailing Address - Street 2:
Mailing Address - City:HURLEYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12747
Mailing Address - Country:US
Mailing Address - Phone:845-866-0801
Mailing Address - Fax:845-985-7070
Practice Address - Street 1:101 KLOTHE DR
Practice Address - Street 2:
Practice Address - City:GRAHAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12740-5805
Practice Address - Country:US
Practice Address - Phone:845-985-7080
Practice Address - Fax:845-985-7070
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator