Provider Demographics
NPI:1750461646
Name:DAVENPORT, MITCHELL K (LCPC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:K
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 W STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1214
Mailing Address - Country:US
Mailing Address - Phone:815-968-9300
Mailing Address - Fax:815-968-5314
Practice Address - Street 1:526 W STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1214
Practice Address - Country:US
Practice Address - Phone:815-968-9300
Practice Address - Fax:815-968-5314
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health