Provider Demographics
NPI:1619205465
Name:DAVIS, BRENDA (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED, 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:PO BOX 7753
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-1753
Mailing Address - Country:US
Mailing Address - Phone:405-640-7045
Mailing Address - Fax:405-702-9397
Practice Address - Street 1:8524 S WESTERN AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9246
Practice Address - Country:US
Practice Address - Phone:405-640-7045
Practice Address - Fax:405-702-9397
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2755235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist