Provider Demographics
NPI:1760428023
Name:DAVISON, JUDITH LYNN (AUD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:DAVISON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 WOODWINDS DRIVE
Mailing Address - Street 2:#240
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-702-0750
Mailing Address - Fax:651-645-6166
Practice Address - Street 1:393 N DUNLAP ST
Practice Address - Street 2:#600
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-645-0691
Practice Address - Fax:651-603-8100
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5414231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN336725800Medicaid