Provider Demographics
NPI:1255578191
Name:DAVENPORT DIAGNOSTIC AND TREATMENT CENTER, INC
Entity type:Organization
Organization Name:DAVENPORT DIAGNOSTIC AND TREATMENT CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:972-850-0720
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:972-850-0720
Mailing Address - Fax:
Practice Address - Street 1:14275 MIDWAY RD
Practice Address - Street 2:SUITE 220
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3614
Practice Address - Country:US
Practice Address - Phone:972-850-0720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32698103TS0200X
TX32578103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty