Provider Demographics
NPI:1396966974
Name:DAVIS, MYRA MEDEIROS (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:MEDEIROS
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 SMOKEY MOUNTAIN TRAIL
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-8150
Mailing Address - Country:US
Mailing Address - Phone:757-548-3546
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDREN'S LANE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507
Practice Address - Country:US
Practice Address - Phone:757-668-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202002413235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202002413OtherVA SPEECH-LANGUAGE PATH