MEDICARE: MICHAEL D DAVIDSON MSW, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SC60790068	WA
2	1041C0700X	Clinical Social Worker	60790068	WA
3	1041C0700X	Clinical Social Worker	LW61180278	WA

General Provider Information

NPI Number	:	1912541566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D DAVIDSON MSW, LICSW

Provider Business Mailing Address
First Line	:	205 E 11TH ST STE LL4
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98660-3311
Country	:	US
Telephone Number	:	360-600-1375
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 E 11TH ST STE LL8
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98660-3311
Country	:	US
Telephone Number	:	360-600-1375
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2019
Last Update Date	:	07/17/2024

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