Provider Demographics
NPI:1255179859
Name:DAVIS, PAUL JOHN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JOHN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11329 POINTE SOUTH CT APT C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-1038
Mailing Address - Country:US
Mailing Address - Phone:314-365-1582
Mailing Address - Fax:
Practice Address - Street 1:11329 POINTE SOUTH CT APT C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-1038
Practice Address - Country:US
Practice Address - Phone:314-365-1582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116149235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist