Provider Demographics
NPI:1508995432
Name:DAVENPORT, LISA CAROL T (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA CAROL
Middle Name:T
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 NW 150TH AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2873
Mailing Address - Country:US
Mailing Address - Phone:786-383-1856
Mailing Address - Fax:786-431-4872
Practice Address - Street 1:17100 ROYAL PALM BOULEVARD
Practice Address - Street 2:SUITE ONE
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326
Practice Address - Country:US
Practice Address - Phone:954-217-2444
Practice Address - Fax:954-217-9292
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7447103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical