Provider Demographics
NPI:1881683969
Name:DAVENPORT, JAMES T (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10713 E DORIC CIR
Mailing Address - Street 2:THE PSYCHOLOGY CENTER INC
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-2220
Mailing Address - Country:US
Mailing Address - Phone:773-238-2828
Mailing Address - Fax:
Practice Address - Street 1:10343 S WESTERN AVE
Practice Address - Street 2:THE PSYCHOLOGY CENTER INC
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2410
Practice Address - Country:US
Practice Address - Phone:773-238-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R18030Medicare UPIN
B913720Medicare ID - Type Unspecified
913720Medicare PIN