Provider Demographics
NPI:1437180916
Name:DAVENPORT, ROBERT M (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 466
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-0466
Mailing Address - Country:US
Mailing Address - Phone:860-693-6226
Mailing Address - Fax:860-693-8002
Practice Address - Street 1:115 SPENCER ST
Practice Address - Street 2:
Practice Address - City:WINSTED
Practice Address - State:CT
Practice Address - Zip Code:06098-1140
Practice Address - Country:US
Practice Address - Phone:860-738-5810
Practice Address - Fax:860-738-5820
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001194Medicare ID - Type Unspecified
CT1058635OtherAETNA
CT080006020CT08OtherBC