Provider Demographics
NPI:1538406061
Name:DAVIDSON, KIMBERLY MARIE (MT-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT-BC
Mailing Address - Street 1:6 ORANGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4914
Mailing Address - Country:US
Mailing Address - Phone:512-633-6450
Mailing Address - Fax:
Practice Address - Street 1:122 WINDSOR AVE
Practice Address - Street 2:FLOOR 2
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2900
Practice Address - Country:US
Practice Address - Phone:860-518-5557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist