Provider Demographics
NPI:1306993035
Name:DAVIS, CHRISTEN (ST)
Entity type:Individual
Prefix:
First Name:CHRISTEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 EARL AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-9566
Mailing Address - Country:US
Mailing Address - Phone:662-843-2339
Mailing Address - Fax:662-846-1397
Practice Address - Street 1:41 EARL AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-9566
Practice Address - Country:US
Practice Address - Phone:662-843-2339
Practice Address - Fax:662-846-1397
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06384301Medicaid