Provider Demographics
NPI:1376915942
Name:DAVIDSON, CARRIE S
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:S
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 MAIN ST STE A272
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4083
Mailing Address - Country:US
Mailing Address - Phone:225-301-2674
Mailing Address - Fax:
Practice Address - Street 1:8888 JEFFERSON HWY STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2427
Practice Address - Country:US
Practice Address - Phone:318-242-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6503101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1376915942Medicaid