Basic Information
| Provider Information | |||||||||
| NPI: | 1063839017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVISON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 186 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GRANTSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261477100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043549244 | ||||||||
| FaxNumber: | 3043549323 | ||||||||
| Practice Location | |||||||||
| Address1: | 186 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GRANTSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261477100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043549244 | ||||||||
| FaxNumber: | 3043549323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2014 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PS005967L | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | 699 | WV | N | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 699 | 01 | WV | STATE LICENSE | OTHER |