Provider Demographics
NPI:1912201237
Name:DAVIS, AUDREY K (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:K
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 1:83 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:24064-1601
Mailing Address - Country:US
Mailing Address - Phone:540-525-3260
Mailing Address - Fax:
Practice Address - Street 1:1009 OLD COUNTRY CLUB RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-2927
Practice Address - Country:US
Practice Address - Phone:540-767-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
VA2202002584235Z00000X
01105990235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist