Basic Information
| Provider Information | |||||||||
| NPI: | 1376915942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2703 MARCH ST | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707912830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256812098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4939 JAMESTOWN AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708083253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259246621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2015 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1376915942 | 05 | LA | MEDICAID |