Provider Demographics
NPI:1699258129
Name:DAVIS, RIELLY (SLP)
Entity type:Individual
Prefix:
First Name:RIELLY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12229 MAPLE CREST DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-3568
Mailing Address - Country:US
Mailing Address - Phone:360-540-2303
Mailing Address - Fax:
Practice Address - Street 1:801 TRAIL RD
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-9302
Practice Address - Country:US
Practice Address - Phone:360-855-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2021-09-30
Deactivation Date:2021-09-08
Deactivation Code:
Reactivation Date:2021-09-30
Provider Licenses
StateLicense IDTaxonomies
WA608685412355S0801X
WASI61194426235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant