Provider Demographics
NPI:1659308104
Name:DAVENPORT, MICHAEL PATRICK (PHD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 HIGHLAND AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-222-6226
Mailing Address - Fax:318-221-8526
Practice Address - Street 1:1002 HIGHLAND AVE
Practice Address - Street 2:STE 300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4143
Practice Address - Country:US
Practice Address - Phone:318-222-6226
Practice Address - Fax:318-221-8526
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA464103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA721409091001OtherHUMANA MILITARY
LA721409091001OtherHUMANA MILITARY