Provider Demographics
NPI:1710291141
Name:DAVIS, ROBERTA RUTH (SLP)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:RUTH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 WATERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7351
Mailing Address - Country:US
Mailing Address - Phone:901-754-6310
Mailing Address - Fax:
Practice Address - Street 1:1970 CORBIN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139-4416
Practice Address - Country:US
Practice Address - Phone:901-262-9682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000001460235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNSP0000001460OtherTN HEALTH RELATED BOARDS LICENSE
TN000535561OtherSTATE OF TN DEPARTMENT OF EDUCATION