Healthcare Provider Details

I. General information

NPI: 1306154885
Provider Name (Legal Business Name): CHARLES ANDREW DAVIDSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHARLIE ANDREW DAVIDSON PHD

II. Dates (important events)

Enumeration Date: 09/19/2010
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1784 CENTURY BLVD NE STE A
ATLANTA GA
30345-3313
US

IV. Provider business mailing address

1784 CENTURY BLVD NE STE A
ATLANTA GA
30345-3313
US

V. Phone/Fax

Practice location:
  • Phone: 402-370-6778
  • Fax:
Mailing address:
  • Phone: 402-370-6778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY004112
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: