Provider Demographics
NPI:1801145586
Name:DAVIS, TERA BARBARA (MA, CCC-SLP/L)
Entity type:Individual
Prefix:MRS
First Name:TERA
Middle Name:BARBARA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24935 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-7466
Mailing Address - Country:US
Mailing Address - Phone:847-322-1059
Mailing Address - Fax:
Practice Address - Street 1:35 TERRACE LN APT F
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3111
Practice Address - Country:US
Practice Address - Phone:847-322-1059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242002472235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL242002472OtherILLINOIS TEMPORARY LICENSE