Healthcare Provider Details

I. General information

NPI: 1053768523
Provider Name (Legal Business Name): DAVEY PROFESSIONAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2016
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3454 VICKSBURG DR
EDWARDSVILLE IL
62025
US

IV. Provider business mailing address

3454 VICKSBURG DRIVE
EDWARDSVILLE IL
62025
US

V. Phone/Fax

Practice location:
  • Phone: 618-541-2040
  • Fax: 618-692-0270
Mailing address:
  • Phone: 618-541-2040
  • Fax: 618-692-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.007858
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number146.007858
License Number StateIL

VIII. Authorized Official

Name: MRS. TERRY KAY DAVEY
Title or Position: SPEECH PATHOLOGIST
Credential: SLP
Phone: 618-541-2040