MEDICARE: MRS. COLLEEN MARIE DAVIS SLP-CCC

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	2004012582	MO

General Provider Information

NPI Number	:	1922142140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COLLEEN MARIE DAVIS SLP-CCC

Provider Business Mailing Address
First Line	:	12430 TESSON FERRY RD
Second Line	:	SUITE 352
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2702
Country	:	US
Telephone Number	:	186-649-5543
Fax Number	:	866-495-2445

Provider Business Practice Location Address
First Line	:	12430 TESSON FERRY RD
Second Line	:	SUITE 352
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2702
Country	:	US
Telephone Number	:	186-649-5543
Fax Number	:	866-495-2445

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/08/2007

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