Provider Demographics
NPI:1386844488
Name:DAVENPORT, PEGGY (LISW)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-3125
Mailing Address - Country:US
Mailing Address - Phone:440-227-9999
Mailing Address - Fax:
Practice Address - Street 1:15 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-3125
Practice Address - Country:US
Practice Address - Phone:440-227-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI07002531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical