Provider Demographics
NPI:1841928306
Name:DAVIS, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 E 30TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-3890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MARTIN MIDDLE SCHOOL
Practice Address - Street 2:1601 HASKELL ST
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702
Practice Address - Country:US
Practice Address - Phone:512-414-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119976235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119976Medicaid