Provider Demographics
NPI:1831221944
Name:DAVENPORT, DEBRA L (MA, SPE)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MA, SPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12595 HIGHWAY 69A
Mailing Address - Street 2:
Mailing Address - City:BIG SANDY
Mailing Address - State:TN
Mailing Address - Zip Code:38221-5066
Mailing Address - Country:US
Mailing Address - Phone:731-584-1012
Mailing Address - Fax:731-584-3102
Practice Address - Street 1:198 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:TN
Practice Address - Zip Code:38320-1609
Practice Address - Country:US
Practice Address - Phone:731-584-1012
Practice Address - Fax:731-584-3102
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE 11334103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441084Medicaid