Provider Demographics
NPI:1801904792
Name:DAVIDSON, LINDA ELLEN (MS)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:ELLEN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MS
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 607
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-0607
Mailing Address - Country:US
Mailing Address - Phone:417-667-9608
Mailing Address - Fax:417-667-9713
Practice Address - Street 1:212 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-2332
Practice Address - Country:US
Practice Address - Phone:417-667-9608
Practice Address - Fax:417-667-9713
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01384103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO24567024OtherBCBS OF KC
MO24567024OtherBCBS OF KC