Provider Demographics
NPI:1093910028
Name:BOULLIOUN-DAVIS, REBECCA (MSE,CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:BOULLIOUN-DAVIS
Suffix:
Gender:F
Credentials:MSE,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14405 OLD RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:72142-9118
Mailing Address - Country:US
Mailing Address - Phone:501-961-9403
Mailing Address - Fax:
Practice Address - Street 1:14405 OLD RIVER DR
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:AR
Practice Address - Zip Code:72142-9118
Practice Address - Country:US
Practice Address - Phone:501-961-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR48235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5H990Medicare PIN