Healthcare Provider Details

I. General information

NPI: 1386957165
Provider Name (Legal Business Name): DEIDRE MARIE DAVIS MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 PARK PL
MOUNT VERNON NY
10552-2321
US

IV. Provider business mailing address

22 PARK PL
MOUNT VERNON NY
10552-2321
US

V. Phone/Fax

Practice location:
  • Phone: 914-668-6541
  • Fax:
Mailing address:
  • Phone: 914-668-6541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number004813-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: