Provider Demographics
NPI:1457011595
Name:DAVENPORT, KIM E (LMHC, LCAC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:E
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LMHC, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 VERNON PL
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8108
Mailing Address - Country:US
Mailing Address - Phone:317-506-5466
Mailing Address - Fax:
Practice Address - Street 1:470 VERNON PL
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8108
Practice Address - Country:US
Practice Address - Phone:317-506-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001263A101YA0400X
IN39003404A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)