Provider Demographics
NPI:1538568407
Name:DAVIDSON, BROOKE NADINE (PSYD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NADINE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 VON KARMAN AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2194
Mailing Address - Country:US
Mailing Address - Phone:949-743-1457
Mailing Address - Fax:
Practice Address - Street 1:4700 VON KARMAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2194
Practice Address - Country:US
Practice Address - Phone:949-743-1457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-17
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31050103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist