Provider Demographics
NPI:1679631527
Name:DAVISON, BRENT (LICSW)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:DAVISON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3710
Mailing Address - Country:US
Mailing Address - Phone:617-605-2279
Mailing Address - Fax:978-281-1739
Practice Address - Street 1:92 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930
Practice Address - Country:US
Practice Address - Phone:617-605-2279
Practice Address - Fax:978-281-1739
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1013691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical