1114021706 NPI number — CAROLINE LOUISE DAVISON LCPC

Table of content: CAROLINE LOUISE DAVISON LCPC (NPI 1114021706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114021706 NPI number — CAROLINE LOUISE DAVISON LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVISON
Provider First Name:
CAROLINE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BIAGIOTTI
Provider Other First Name:
CAROLINE
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114021706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
78 ATLANTIC PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-2316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-842-7701
Provider Business Mailing Address Fax Number:
207-842-7773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 WESTBROOK CMN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTBROOK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04092-2819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-856-1500
Provider Business Practice Location Address Fax Number:
207-856-1518
Provider Enumeration Date:
09/12/2006

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: 101YP2500X , with the licence number:  CC3147 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 418000099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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