Provider Demographics
NPI:1023653235
Name:DAVIDSON, ELLEN L
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 S STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4356
Mailing Address - Country:US
Mailing Address - Phone:812-391-6779
Mailing Address - Fax:
Practice Address - Street 1:3013 S STRATFORD DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4356
Practice Address - Country:US
Practice Address - Phone:812-391-6779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst