Provider Demographics
NPI:1457505539
Name:DAVIS, DIANE MARSH (MA CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARSH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WOODCHUCK PATH
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2124
Mailing Address - Country:US
Mailing Address - Phone:631-929-6610
Mailing Address - Fax:
Practice Address - Street 1:4747-8 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2878
Practice Address - Country:US
Practice Address - Phone:631-331-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-16
Last Update Date:2008-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY882231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter