MEDICARE: SHELLEY DAVIDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	101521	TX

General Provider Information

NPI Number	:	1578979035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY DAVIDSON

Provider Business Mailing Address
First Line	:	104 BLUE BONNET CIR
Second Line	:
City	:	JUSTIN
State	:	TX
Zip	:	76247-5813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6850 MANHATTAN BLVD STE 204
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76120-1210
Country	:	US
Telephone Number	:	817-507-1500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2014
Last Update Date	:	07/05/2014

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Directions to “ SHELLEY DAVIDSON ” Practice Location

Language	Start Address	Practice Location

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