Basic Information
| Provider Information | |||||||||
| NPI: | 1053346742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., L.P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 IMPERIAL HEIGHTS RD | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286258969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048763242 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1309 S CANNON BLVD | ||||||||
| Address2: | |||||||||
| City: | KANNAPOLIS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280836232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049333212 | ||||||||
| FaxNumber: | 7049333221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 11/28/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2488 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6107125 | 05 | NC | MEDICAID |