Provider Demographics
NPI:1952441149
Name:DAVIS, DIANE (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:DIANE
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 1:8050 OLD CR 54
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6457
Mailing Address - Country:US
Mailing Address - Phone:727-375-0600
Mailing Address - Fax:727-375-1117
Practice Address - Street 1:8050 OLD CR 54
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-6457
Practice Address - Country:US
Practice Address - Phone:727-375-0600
Practice Address - Fax:727-375-1117
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS1760OtherBLUE CROSS BLUE SHIELD
FL215753OtherAMERIGROUP NUMBER
FL880842200Medicaid
FL10620902OtherCITRUS INDIVIDUAL NUM SH
FL10620901OtherCITURS INDIVIDUAL NUM NPR
FL282700OtherAVMED