1083926182 NPI number — MRS. AMANDA RUTH DAVIDSON B.C.B.A.

Table of content: MRS. AMANDA RUTH DAVIDSON B.C.B.A. (NPI 1083926182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083926182 NPI number — MRS. AMANDA RUTH DAVIDSON B.C.B.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
AMANDA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
B.C.B.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GISBERT
Provider Other First Name:
AMANDA
Provider Other Middle Name:
RUTH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083926182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 BARTRAM MARKET DR STE 135-286
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOHNS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32259-4581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-827-3886
Provider Business Mailing Address Fax Number:
844-380-4778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 BARTRAM MARKET DR STE 135-286
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOHNS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32259-4581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-827-3886
Provider Business Practice Location Address Fax Number:
844-380-4778
Provider Enumeration Date:
07/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-09-6647 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 023751100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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