Provider Demographics
NPI:1053768523
Name:DAVEY PROFESSIONAL SERVICES LLC
Entity type:Organization
Organization Name:DAVEY PROFESSIONAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:DAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:618-541-2040
Mailing Address - Street 1:3454 VICKSBURG DRIVE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025
Mailing Address - Country:US
Mailing Address - Phone:618-541-2040
Mailing Address - Fax:618-692-0270
Practice Address - Street 1:3454 VICKSBURG DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025
Practice Address - Country:US
Practice Address - Phone:618-541-2040
Practice Address - Fax:618-692-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-15
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.007858235Z00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty