Provider Demographics
NPI:1841716925
Name:DAVIS, MANDA (MS/CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:MANDA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS/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 1:7643 E SANDWICH RD
Mailing Address - Street 2:
Mailing Address - City:HINCKLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60520-6038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:IL
Practice Address - Zip Code:60520-9002
Practice Address - Country:US
Practice Address - Phone:815-286-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-20
Last Update Date:2017-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist