Provider Demographics
NPI:1124218318
Name:DAVENPORT, KAREN B (PHD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:B
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:BISSIRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 CORTLAND SHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3944
Mailing Address - Country:US
Mailing Address - Phone:856-261-0067
Mailing Address - Fax:609-261-7199
Practice Address - Street 1:92 BRICK RD
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2177
Practice Address - Country:US
Practice Address - Phone:856-988-4127
Practice Address - Fax:609-261-7199
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00404200103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP40916Medicare UPIN
NJ051307Medicare PIN