Provider Demographics
NPI:1720330210
Name:DAVIS, CARLY MARIE (SLP)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4028 HOLCOMB BRIDGE RD
Mailing Address - Street 2:STE 202
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4655
Mailing Address - Country:US
Mailing Address - Phone:770-209-9826
Mailing Address - Fax:
Practice Address - Street 1:4028 HOLCOMB BRIDGE RD
Practice Address - Street 2:STE 202
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4655
Practice Address - Country:US
Practice Address - Phone:770-209-9826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist