Healthcare Provider Details

I. General information

NPI: 1730650532
Provider Name (Legal Business Name): DEJA DAVIDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LAKESIDE BLVD STE 115
RICHARDSON TX
75082-4341
US

IV. Provider business mailing address

2400 LAKESIDE BLVD STE 115
RICHARDSON TX
75082-4341
US

V. Phone/Fax

Practice location:
  • Phone: 214-684-9811
  • Fax:
Mailing address:
  • Phone: 214-684-9811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number96290
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: