Basic Information
| Provider Information | |||||||||
| NPI: | 1487856159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVISON | ||||||||
| FirstName: | TAMARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1603 MEDICAL DR STE A | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283525541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102767011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1603 MEDICAL DR STE A | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283525541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102767011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3789 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6102963 | 05 | NC | MEDICAID |