Provider Demographics
NPI:1497818116
Name:DAVENPORT, ELIZABETH (LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:E
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:4 ANGIER RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420
Mailing Address - Country:US
Mailing Address - Phone:781-862-4907
Mailing Address - Fax:
Practice Address - Street 1:740 MAIN ST
Practice Address - Street 2:SUITE #105
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451
Practice Address - Country:US
Practice Address - Phone:781-937-4172
Practice Address - Fax:781-734-0482
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1002141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P04346OtherBLUE CROSS BLUE SHIELD
P04346OtherBLUE CROSS BLUE SHIELD