Provider Demographics
NPI:1023205127
Name:DAVENPORT, MICHELLE (OTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 COUNTY ROAD 2091
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-6726
Mailing Address - Country:US
Mailing Address - Phone:903-238-4252
Mailing Address - Fax:
Practice Address - Street 1:601 HOLLYBROOK DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2418
Practice Address - Country:US
Practice Address - Phone:903-758-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121571225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist