Provider Demographics
NPI:1366893794
Name:DAVISSON, ANGELIQUE (MS,CCC/SLP)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:DAVISSON
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 1:2002 AIRLINE RD
Mailing Address - Street 2:APARTMENT # 301
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-4600
Mailing Address - Country:US
Mailing Address - Phone:361-853-0488
Mailing Address - Fax:361-853-0489
Practice Address - Street 1:1001 LOUISIANA AVE STE 402
Practice Address - Street 2:APARTMENT # 301
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2856
Practice Address - Country:US
Practice Address - Phone:361-853-0488
Practice Address - Fax:361-853-0489
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108022235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist