Provider Demographics
NPI:1265185409
Name:DAVENPORT, LARRY PAUL
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:PAUL
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-8590
Practice Address - Country:US
Practice Address - Phone:606-256-2143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2564661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical