MEDICARE: MRS. DEIDRE MARIE DAVIS MS CCC-SLP

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	004813-1	NY

General Provider Information

NPI Number	:	1386957165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEIDRE MARIE DAVIS MS CCC-SLP

Provider Business Mailing Address
First Line	:	22 PARK PL
Second Line	:
City	:	MOUNT VERNON
State	:	NY
Zip	:	10552-2321
Country	:	US
Telephone Number	:	914-668-6541
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 PARK PL
Second Line	:
City	:	MOUNT VERNON
State	:	NY
Zip	:	10552-2321
Country	:	US
Telephone Number	:	914-668-6541
Fax Number	:

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

Provider Enumeration Date	:	07/21/2010
Last Update Date	:	07/21/2010

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Directions to “ MRS. DEIDRE MARIE DAVIS MS CCC-SLP” Practice Location

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