Provider Demographics
NPI:1861830820
Name:DAVIDSON, JOAN
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 COLLEGE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1590
Mailing Address - Country:US
Mailing Address - Phone:510-652-4455
Mailing Address - Fax:510-380-2988
Practice Address - Street 1:5435 COLLEGE AVE STE 103
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1590
Practice Address - Country:US
Practice Address - Phone:510-652-4455
Practice Address - Fax:510-380-2988
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14532103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical