Provider Demographics
NPI:1073654547
Name:DIANE DAVIS PA
Entity Type:Organization
Organization Name:DIANE DAVIS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:727-375-0600
Mailing Address - Street 1:8050 OLD CR 54
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6457
Mailing Address - Country:US
Mailing Address - Phone:727-375-0600
Mailing Address - Fax:727-375-1117
Practice Address - Street 1:8050 OLD CR 54
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-6457
Practice Address - Country:US
Practice Address - Phone:727-375-0600
Practice Address - Fax:727-375-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5926235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10647201OtherCITRUS NPR GROUP
FL282700OtherAVMED
FLS1760OtherBCBS
FL10647202OtherCITRUS SH GROUP
FL704024OtherACN GROUP
FL215753OtherAMERIGROUP
FL885702400Medicaid