Provider Demographics
NPI:1194092395
Name:DAVIDSON, TODD M (CDPT)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 W. 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363
Mailing Address - Country:US
Mailing Address - Phone:360-452-5014
Mailing Address - Fax:
Practice Address - Street 1:1001 BAY VIEW AVE.
Practice Address - Street 2:
Practice Address - City:NEAH BAY
Practice Address - State:WA
Practice Address - Zip Code:98357
Practice Address - Country:US
Practice Address - Phone:360-645-2461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60124036101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO 60124036OtherCHEMICAL DEPENDENCY PROFESSIONAL TRAINEE