Provider Demographics
NPI:1902462500
Name:DAVISON, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:DAVISON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9514 OCEAN DR
Mailing Address - Street 2:
Mailing Address - City:IOWA COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:77583-1603
Mailing Address - Country:US
Mailing Address - Phone:281-630-1113
Mailing Address - Fax:
Practice Address - Street 1:9514 OCEAN DR
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-1603
Practice Address - Country:US
Practice Address - Phone:281-241-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2025-03-17
Deactivation Date:2019-05-21
Deactivation Code:
Reactivation Date:2019-06-10
Provider Licenses
StateLicense IDTaxonomies
TX78160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional