Provider Demographics
NPI:1124377577
Name:BECKET-DAVENPORT, COLLEEN MARIE
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MARIE
Last Name:BECKET-DAVENPORT
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 1:795 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-2539
Mailing Address - Country:US
Mailing Address - Phone:415-236-2499
Mailing Address - Fax:
Practice Address - Street 1:1015 AILEEN ST
Practice Address - Street 2:D
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-2710
Practice Address - Country:US
Practice Address - Phone:707-373-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30368103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical