Provider Demographics
NPI:1033390604
Name:DAVENPORT ODIBO, WANDA
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:
Last Name:DAVENPORT ODIBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 DAISY DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75134-1635
Mailing Address - Country:US
Mailing Address - Phone:972-948-8314
Mailing Address - Fax:
Practice Address - Street 1:1431 DAISY DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75134-1635
Practice Address - Country:US
Practice Address - Phone:972-948-8314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15391101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional