Provider Demographics
NPI:1578896767
Name:DAVIS, COLLEEN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 SEXTON RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-8848
Mailing Address - Country:US
Mailing Address - Phone:248-321-7825
Mailing Address - Fax:
Practice Address - Street 1:977 SEXTON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8848
Practice Address - Country:US
Practice Address - Phone:248-321-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-07
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIASHA 12111117235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist