Basic Information
| Provider Information | |||||||||
| NPI: | 1235341751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RD, MS, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 HAVERHILL ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018412884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786860090 | ||||||||
| FaxNumber: | 9786815963 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 HAVERHILL ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018412884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786860090 | ||||||||
| FaxNumber: | 9786815963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 01/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 4093 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | 136A00000X | 0802 | NH | N | Dietary & Nutritional Service Providers | Dietetic Technician, Registered |
No ID Information.