Provider Demographics
NPI:1134166275
Name:DAVENPORT, SHELLY MARIE (MS, LMFT)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:MARIE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:MARIE
Other - Last Name:BRITTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NONE AT THE TIME
Mailing Address - Street 1:11141 ZEALAND AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3595
Mailing Address - Country:US
Mailing Address - Phone:763-951-3091
Mailing Address - Fax:763-951-3097
Practice Address - Street 1:11141 ZEALAND AVE N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316
Practice Address - Country:US
Practice Address - Phone:763-951-3091
Practice Address - Fax:763-951-3097
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1139106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN407168900Medicaid