Provider Demographics
NPI:1750690079
Name:DAVENPORT, BRENDA (LMT)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3244 LORIMAR LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-6503
Mailing Address - Country:US
Mailing Address - Phone:407-957-7694
Mailing Address - Fax:
Practice Address - Street 1:3244 LORIMAR LN
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-6503
Practice Address - Country:US
Practice Address - Phone:407-957-7694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 52729225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist