Provider Demographics
NPI:1891987020
Name:DAVENPORT, LERA JOSIE (LMT, LCSW)
Entity Type:Individual
Prefix:
First Name:LERA
Middle Name:JOSIE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LMT, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-5419
Mailing Address - Country:US
Mailing Address - Phone:352-514-5076
Mailing Address - Fax:352-373-3950
Practice Address - Street 1:6421 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-5419
Practice Address - Country:US
Practice Address - Phone:352-514-5076
Practice Address - Fax:352-373-3950
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-12
Last Update Date:2007-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 51301041C0700X
FLMA 3599247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL#C8547 LMTOtherBLUE CROSS/BLUE SHIELD
FL#Z8967 LCSWOtherBLUE CROSS/BLUE SHIELD