Provider Demographics
NPI:1457493504
Name:DAVIS, JUDI
Entity Type:Individual
Prefix:
First Name:JUDI
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9310 E SARA ELYSE LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3206
Mailing Address - Country:US
Mailing Address - Phone:520-290-1992
Mailing Address - Fax:
Practice Address - Street 1:450 S MONTEGO DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3796
Practice Address - Country:US
Practice Address - Phone:520-731-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL2164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ752396OtherAHCCCS PROVIDER #