Provider Demographics
NPI:1902533300
Name:DAVIDSON, MALLORY (MSED)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 FIRE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3516
Mailing Address - Country:US
Mailing Address - Phone:516-457-1027
Mailing Address - Fax:
Practice Address - Street 1:1018 FIRE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3516
Practice Address - Country:US
Practice Address - Phone:516-457-1027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool