Provider Demographics
NPI:1710595434
Name:DAVENPORT, MELANIE JOY (LMSW, CLINICAL)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:JOY
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LMSW, CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 E MILWAUKEE ST # 6606
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-8200
Mailing Address - Country:US
Mailing Address - Phone:313-580-6825
Mailing Address - Fax:
Practice Address - Street 1:306 S WASHINGTON AVE STE 226
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3833
Practice Address - Country:US
Practice Address - Phone:866-600-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011152741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801115274OtherLARA MICHIGAN