Provider Demographics
NPI:1588149975
Name:DAVIS, BRENNA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BRENNA
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 1:2519 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1405
Mailing Address - Country:US
Mailing Address - Phone:414-379-7446
Mailing Address - Fax:
Practice Address - Street 1:2519 N 64TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1405
Practice Address - Country:US
Practice Address - Phone:414-379-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1015912299235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1015912299OtherWISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION