Provider Demographics
NPI:1568962421
Name:DAVENPORT, DONALD CHARLES
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:CHARLES
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 1:6735 SHORT LN
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-4314
Mailing Address - Country:US
Mailing Address - Phone:267-721-5676
Mailing Address - Fax:
Practice Address - Street 1:6735 SHORT LN
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-4314
Practice Address - Country:US
Practice Address - Phone:267-721-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-17
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001344103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA$$$$$$$$$OtherSSI