Provider Demographics
NPI:1841052503
Name:DAVIDSON, DYLAN TAYLOR (CPSS)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:TAYLOR
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 W CHARLOTTE AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4253
Mailing Address - Country:US
Mailing Address - Phone:803-848-1839
Mailing Address - Fax:
Practice Address - Street 1:208 KING ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-4720
Practice Address - Country:US
Practice Address - Phone:803-432-6902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist