Provider Demographics
NPI:1508132572
Name:DAVENPORT, ELIJAH
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:
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 22922
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96823-2922
Mailing Address - Country:US
Mailing Address - Phone:808-450-4344
Mailing Address - Fax:
Practice Address - Street 1:615 PIIKOI ST
Practice Address - Street 2:SUITE 203
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3116
Practice Address - Country:US
Practice Address - Phone:808-589-1829
Practice Address - Fax:808-589-2610
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW-47741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical