Provider Demographics
NPI:1497421044
Name:DAVENPORT, CONNIE LYNN
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LYNN
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 GI MADDOX PKWY
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-2069
Mailing Address - Country:US
Mailing Address - Phone:706-971-3366
Mailing Address - Fax:706-426-0949
Practice Address - Street 1:1289 GI MADDOX PKWY
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2069
Practice Address - Country:US
Practice Address - Phone:706-971-3366
Practice Address - Fax:706-426-0949
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)