Provider Demographics
NPI:1639168297
Name:DAVENPORT, GLENDA L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:L
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LCSW
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 1996
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-1996
Mailing Address - Country:US
Mailing Address - Phone:727-560-8225
Mailing Address - Fax:727-942-0252
Practice Address - Street 1:430 ATHENS ST
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3104
Practice Address - Country:US
Practice Address - Phone:727-560-8225
Practice Address - Fax:727-942-0252
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW35381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110337OtherAMERIGROUP
FLSW3538OtherLCSW
FL0005848678OtherAETNA
FL104602OtherVALUE OPTIONS
FL6223259OtherUNITED HEALTHCARE
FL6223259OtherUNITED HEALTHCARE
FLP85247Medicare UPIN