Provider Demographics
NPI:1558402420
Name:DAVENPORT, ROSEANNE MARIE (LMSW, ACSW)
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:MARIE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4388 SEDUM GLN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1151
Mailing Address - Country:US
Mailing Address - Phone:248-568-4524
Mailing Address - Fax:
Practice Address - Street 1:8062 ORTONVILLE ROAD
Practice Address - Street 2:TRIAD ASSOCIATES, P.C.
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348
Practice Address - Country:US
Practice Address - Phone:248-625-2970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010208481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM59870005Medicare ID - Type Unspecified