Provider Demographics
NPI:1740490929
Name:DAVENPORT, ELIZABETH SHANNON (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SHANNON
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 BENSON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7321
Mailing Address - Country:US
Mailing Address - Phone:919-878-7800
Mailing Address - Fax:919-878-9983
Practice Address - Street 1:3710 BENSON DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7321
Practice Address - Country:US
Practice Address - Phone:919-878-7800
Practice Address - Fax:919-878-9983
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0018831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2870097Medicare ID - Type Unspecified