Provider Demographics
NPI:1679980619
Name:DAVIDSON, KATHLEEN J (LCAC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8495 E 150 S
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-8396
Mailing Address - Country:US
Mailing Address - Phone:219-928-1944
Mailing Address - Fax:574-936-3910
Practice Address - Street 1:322 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1734
Practice Address - Country:US
Practice Address - Phone:574-936-3377
Practice Address - Fax:574-936-3910
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001530A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)