Provider Demographics
NPI:1992983407
Name:DAVIDSON, RICHARD DAVID (MS, LADC, CRC, CVRT,)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MS, LADC, CRC, CVRT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 S ELM PL
Mailing Address - Street 2:SUITE 3718
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-1803
Mailing Address - Country:US
Mailing Address - Phone:918-994-1510
Mailing Address - Fax:
Practice Address - Street 1:3718 S ELM PL
Practice Address - Street 2:SUITE 3718
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-1803
Practice Address - Country:US
Practice Address - Phone:918-994-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1992983407Medicaid