Provider Demographics
NPI:1689986705
Name:DAVIS, KRISTINA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
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 1:1412 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:62018-1427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT ANTHONYS WAY
Practice Address - Street 2:OUTPATIENT THERAPY SERVICES
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4568
Practice Address - Country:US
Practice Address - Phone:618-465-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.007856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist