Provider Demographics
NPI:1306008420
Name:DAVIS, BETTINA NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7112 S MINGO RD STE 108
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-3267
Mailing Address - Country:US
Mailing Address - Phone:18-250-7093
Mailing Address - Fax:918-250-9976
Practice Address - Street 1:7112 S MINGO RD STE 108
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-3267
Practice Address - Country:US
Practice Address - Phone:18-250-7093
Practice Address - Fax:918-250-9976
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3424235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKTO BE ASSIGNEDMedicaid