Provider Demographics
NPI:1427145465
Name:DAVIDSON, JUDITH A (MA)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 MAIN ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-7128
Mailing Address - Country:US
Mailing Address - Phone:802-257-1660
Mailing Address - Fax:
Practice Address - Street 1:167 MAIN ST
Practice Address - Street 2:SUITE 401
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7128
Practice Address - Country:US
Practice Address - Phone:802-257-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT206103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT410046OtherMVP PROVIDER NUMBER
VT0006569Medicaid
VT062-6569OtherBLUE CROSS/BLUE SHIELD