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: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 LEXINGTON ST STE 300
WALTHAM MA
02452-4401
US

IV. Provider business mailing address

6 LEXINGTON ST
WALTHAM MA
02452-4401
US

V. Phone/Fax

Practice location:
  • Phone: 978-662-1002
  • Fax: 978-767-4757
Mailing address:
  • Phone: 978-662-1002
  • Fax: 978-767-4757

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: