Provider Demographics
NPI:1770567562
Name:DAVENPORT-HOLLADAY, KIMBERLI KEVIN (MS CCCA)
Entity type:Individual
Prefix:MS
First Name:KIMBERLI
Middle Name:KEVIN
Last Name:DAVENPORT-HOLLADAY
Suffix:
Gender:F
Credentials:MS CCCA
Other - Prefix:
Other - First Name:KIMBERLI
Other - Middle Name:
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5620 SE LAMBERT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206
Mailing Address - Country:US
Mailing Address - Phone:503-475-1266
Mailing Address - Fax:
Practice Address - Street 1:2860 SE HOLGATE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3658
Practice Address - Country:US
Practice Address - Phone:503-234-7843
Practice Address - Fax:503-235-6973
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22613231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist