Provider Demographics
NPI:1992189849
Name:DAVENPORT, DANIELLE RYAN
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:RYAN
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:RYAN
Other - Last Name:HARRELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-474-8921
Mailing Address - Fax:
Practice Address - Street 1:309 PINEYWOOD RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3438
Practice Address - Country:US
Practice Address - Phone:336-474-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC11805101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health