Provider Demographics
NPI:1457805715
Name:DAVENPORT, CELIA DAWN (MAT, LBS1)
Entity Type:Individual
Prefix:
First Name:CELIA
Middle Name:DAWN
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MAT, LBS1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 N ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5011
Mailing Address - Country:US
Mailing Address - Phone:312-243-8487
Mailing Address - Fax:888-733-1772
Practice Address - Street 1:304 N LOOMIS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1147
Practice Address - Country:US
Practice Address - Phone:312-243-8487
Practice Address - Fax:888-733-1772
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL989306103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst