Provider Demographics
NPI:1710294749
Name:DAVENPORT, ANNETTA M G (LMHC)
Entity Type:Individual
Prefix:MS
First Name:ANNETTA
Middle Name:M G
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E MIRACLE STRIP PKWY STE 204
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1990
Mailing Address - Country:US
Mailing Address - Phone:850-226-7100
Mailing Address - Fax:850-226-7157
Practice Address - Street 1:124 E MIRACLE STRIP PKWY STE 204
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1990
Practice Address - Country:US
Practice Address - Phone:850-226-7100
Practice Address - Fax:850-226-7157
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9997101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional