1801145586 NPI number — MRS. TERA BARBARA DAVIS MA, CCC-SLP/L

Table of content: MRS. TERA BARBARA DAVIS MA, CCC-SLP/L (NPI 1801145586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801145586 NPI number — MRS. TERA BARBARA DAVIS MA, CCC-SLP/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
TERA
Provider Middle Name:
BARBARA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-SLP/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801145586
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24935 JORDAN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60544-7466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-322-1059
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 TERRACE LN APT F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ZURICH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-322-1059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  242002472 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 242002472 . This is a "ILLINOIS TEMPORARY LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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