Provider Demographics
NPI:1245606763
Name:DAVIS, MARY GRACE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26420 KENSINGTON PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-5120
Mailing Address - Country:US
Mailing Address - Phone:251-517-0355
Mailing Address - Fax:251-625-1969
Practice Address - Street 1:26420 KENSINGTON PL
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-5120
Practice Address - Country:US
Practice Address - Phone:251-517-0355
Practice Address - Fax:251-625-1969
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist