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General NPI Number Information
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NPI Number | 1609608280
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Entity Type | Individual
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Provider Name | MATTHEW SHANE DAVIDSON PEER SPECIALIST
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Gender | Male
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Dates
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Enumeration Date | 08/14/2024
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Last Update Date | 06/04/2025
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Provider Practice Location Address
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Address Line | 1006 BEAR LANE
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City | OKMULGEE
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State | OK
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Zip | 74447
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Country | US
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Telephone | 918-549-2643
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 580
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City | OKMULGEE
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State | OK
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Zip | 74447-0580
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Country | US
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Telephone | 918-549-2643
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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