Provider Demographics
NPI:1740810811
Name:DAVENPORT, DANA ANTOINE
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:ANTOINE
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 1:19 E 3RD ST APT 44
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-4268
Mailing Address - Country:US
Mailing Address - Phone:804-839-2436
Mailing Address - Fax:
Practice Address - Street 1:19 E 3RD ST APT 44
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-4268
Practice Address - Country:US
Practice Address - Phone:804-839-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008417101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional