Provider Demographics
NPI:1922547181
Name:DAVENPORT, AMANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MAIN ST
Mailing Address - Street 2:SUITE 217
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3225
Mailing Address - Country:US
Mailing Address - Phone:706-668-5035
Mailing Address - Fax:706-243-4939
Practice Address - Street 1:102 MAIN ST
Practice Address - Street 2:SUITE 217
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3225
Practice Address - Country:US
Practice Address - Phone:706-668-5035
Practice Address - Fax:706-243-4939
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0056061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical