Provider Demographics
NPI:1467870048
Name:DAVENPORT, ELISE LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:LOUISE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SW COLUMBIA ST
Mailing Address - Street 2:SUITE 6210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:541-383-1883
Practice Address - Street 1:600 SW COLUMBIA ST
Practice Address - Street 2:SUITE 6210
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1099
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL6685101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR189337Medicare PIN