Provider Demographics
NPI:1649704909
Name:DAVIS, RANDAL (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:RANDAL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11044 N 2040 RD
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-9386
Mailing Address - Country:US
Mailing Address - Phone:580-243-9818
Mailing Address - Fax:
Practice Address - Street 1:11044 N 2040 RD
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-9386
Practice Address - Country:US
Practice Address - Phone:580-243-9818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4070235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist