MEDICARE: ANDREY DAVYDOV LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	17683	FL

General Provider Information

NPI Number	:	1801497185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREY DAVYDOV LCSW

Provider Business Mailing Address
First Line	:	3800 N HILLS DR APT 106
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-2541
Country	:	US
Telephone Number	:	917-463-6553
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 N HILLS DR APT 106
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-2541
Country	:	US
Telephone Number	:	917-463-6553
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2020
Last Update Date	:	11/04/2020

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