Provider Demographics
NPI:1922166594
Name:DAVIS, KAREN (MED,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAREN
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 1:582C FARRINGDOM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2615
Mailing Address - Country:US
Mailing Address - Phone:910-735-1101
Mailing Address - Fax:910-735-1103
Practice Address - Street 1:582C FARRINGDOM ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2615
Practice Address - Country:US
Practice Address - Phone:910-735-1101
Practice Address - Fax:910-735-1103
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005365235Z00000X
NC10621235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000961683DMedicaid