Provider Demographics
NPI:1871801886
Name:DAVIDSON, CHAUNCEY
Entity type:Individual
Prefix:
First Name:CHAUNCEY
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353
Mailing Address - Country:US
Mailing Address - Phone:704-449-8511
Mailing Address - Fax:
Practice Address - Street 1:4400 SOUTH JONES BLVD
Practice Address - Street 2:STE. 1055
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103
Practice Address - Country:US
Practice Address - Phone:704-449-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health