Healthcare Provider Details

I. General information

NPI: 1831885615
Provider Name (Legal Business Name): SAMUEL DAVIDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

IV. Provider business mailing address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-5000
  • Fax: 617-636-8642
Mailing address:
  • Phone: 617-636-5000
  • Fax: 617-636-8642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2338730
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2338730
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: