Provider Demographics
NPI:1316062755
Name:DAVIDSON, MARIE ANNE (PHD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANNE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 JUNIPER TERRACE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3323
Mailing Address - Country:US
Mailing Address - Phone:847-486-9106
Mailing Address - Fax:847-486-1995
Practice Address - Street 1:5225 OLD ORCHARD RD
Practice Address - Street 2:STE 1
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077
Practice Address - Country:US
Practice Address - Phone:847-486-9106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical