Basic Information
| Provider Information | |||||||||
| NPI: | 1821364001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | COLLIN | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4419 WENTWORTH AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554194941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056123428 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 W LAKE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554083565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033998020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2012 | ||||||||
| LastUpdateDate: | 07/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103TB0200X | LP5748 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No ID Information.