Provider Demographics
NPI:1245601897
Name:DAVIS, RAEVYNN (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:RAEVYNN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:RAEVYNN
Other - Middle Name:
Other - Last Name:LEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP-CCC
Mailing Address - Street 1:PO BOX 8114
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37414-0114
Mailing Address - Country:US
Mailing Address - Phone:423-622-1551
Mailing Address - Fax:877-856-7133
Practice Address - Street 1:695 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066
Practice Address - Country:US
Practice Address - Phone:423-622-1551
Practice Address - Fax:877-856-7133
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist