Healthcare Provider Details

I. General information

NPI: 1376262352
Provider Name (Legal Business Name): ROBERT SCOTT DAVIDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11980 SAN VICENTE BLVD STE 805
LOS ANGELES CA
90049-6606
US

IV. Provider business mailing address

3868 S CENTINELA AVE APT 18
LOS ANGELES CA
90066-4459
US

V. Phone/Fax

Practice location:
  • Phone: 202-412-7644
  • Fax:
Mailing address:
  • Phone: 202-412-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number36068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: