Provider Demographics
NPI:1912002155
Name:KENT, MARCIA DAVENPORT (MD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:DAVENPORT
Last Name:KENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 MICHIGAN ST NE STE 5201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2530
Practice Address - Country:US
Practice Address - Phone:616-267-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010708322084F0202X, 2084P0800X, 2084P0804X, 2084P0804X, 2084P0800X
WAMD 000389402084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602 629 831OtherUNIFIED BUSINESS ID #
20-5333219OtherEMPLOYER IDENTIFICATION #
WAMD00038940OtherMEDICAL LISCENSE
WAI03916Medicare UPIN
WAMD00038940OtherMEDICAL LISCENSE