1285687889 NPI number — CHARME S. DAVIDSON PH.D., ABPP

Table of content: CHARME S. DAVIDSON PH.D., ABPP (NPI 1285687889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285687889 NPI number — CHARME S. DAVIDSON PH.D., ABPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
CHARME
Provider Middle Name:
S.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D., ABPP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285687889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 PLEASANT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55419-1846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-825-2868
Provider Business Mailing Address Fax Number:
612-870-4542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 WILLOW ST
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55403-2269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-870-0510
Provider Business Practice Location Address Fax Number:
612-870-4542
Provider Enumeration Date:
05/18/2006

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: 103T00000X , with the licence number:  LP2642 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: MFT0245 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 6275478000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: LP2642 . This is a "MN PSYCHOLOGY LICENSE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0245 . This is a "MN MARRIAGE & FAM LIC #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3962 . This is a "ABPP #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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