Provider Demographics
NPI:1760612469
Name:DAVENPORT, RICHARD AUSTIN (LMP)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:AUSTIN
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2491
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-2491
Mailing Address - Country:US
Mailing Address - Phone:360-298-6848
Mailing Address - Fax:
Practice Address - Street 1:285 SPRING ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98250
Practice Address - Country:US
Practice Address - Phone:360-378-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60091736225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist