Provider Demographics
NPI:1053346742
Name:DAVIDSON, KEVIN BRIAN (MA, LPA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:BRIAN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 IMPERIAL HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-8969
Mailing Address - Country:US
Mailing Address - Phone:704-876-3242
Mailing Address - Fax:
Practice Address - Street 1:1309 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6232
Practice Address - Country:US
Practice Address - Phone:704-933-3212
Practice Address - Fax:704-933-3221
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2488103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107125Medicaid