Basic Information
Provider Information | |||||||||
NPI: | 1922253798 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIDSON | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | L B | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BERRY | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 17 HAWKES TRL | ||||||||
Address2: |   | ||||||||
City: | WEBSTER | ||||||||
State: | NY | ||||||||
PostalCode: | 145804210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5855077203 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FAIRPORT | ||||||||
State: | NY | ||||||||
PostalCode: | 144501524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5853776590 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2008 | ||||||||
LastUpdateDate: | 02/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 58018463 | NY | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.