Provider Demographics
NPI:1821462805
Name:DAVENPORT, JOHN RUSSELL (LPCA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 COX RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3424
Mailing Address - Country:US
Mailing Address - Phone:704-691-7561
Mailing Address - Fax:
Practice Address - Street 1:635 COX RD
Practice Address - Street 2:SUITE B
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3424
Practice Address - Country:US
Practice Address - Phone:704-691-7561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11964101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional