Provider Demographics
NPI:1417324195
Name:DAVIS, TIFFANY (MS/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
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 1:500 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9007
Mailing Address - Country:US
Mailing Address - Phone:816-892-3999
Mailing Address - Fax:
Practice Address - Street 1:500 S MADISON ST
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-9007
Practice Address - Country:US
Practice Address - Phone:816-892-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011016428235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO019-192Medicaid