Provider Demographics
NPI:1346751740
Name:DAVENPORT, DARIC (LCSW)
Entity Type:Individual
Prefix:
First Name:DARIC
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 EUSTIS PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5173
Mailing Address - Country:US
Mailing Address - Phone:207-716-7041
Mailing Address - Fax:
Practice Address - Street 1:67 EUSTIS PKWY
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5173
Practice Address - Country:US
Practice Address - Phone:207-873-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC185461041C0700X
MEMC16853101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor