Provider Demographics
NPI:1730487844
Name:M PATRICK DAVENPORT APPC
Entity Type:Organization
Organization Name:M PATRICK DAVENPORT APPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-518-5001
Mailing Address - Street 1:1002 HIGHLAND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4143
Mailing Address - Country:US
Mailing Address - Phone:318-222-6226
Mailing Address - Fax:318-222-6227
Practice Address - Street 1:1002 HIGHLAND AVE
Practice Address - Street 2:3RD FLOOR
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:318-222-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-14
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA464103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty