Provider Demographics
NPI:1932138765
Name:DAVENPORT, CANDIDA AMBER (LAC, LADC)
Entity Type:Individual
Prefix:MRS
First Name:CANDIDA
Middle Name:AMBER
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LAC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 FORESTVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-5910
Mailing Address - Country:US
Mailing Address - Phone:763-546-8008
Mailing Address - Fax:763-546-7674
Practice Address - Street 1:115 FORESTVIEW LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-5910
Practice Address - Country:US
Practice Address - Phone:763-546-8008
Practice Address - Fax:763-546-7674
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1492101YA0400X
MN303356101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN92OS7KIOtherBCBS MN PROVIDER NUMBER
ND054519Medicaid
ND022581OtherBCBS ND PROVIDER NUMBER