Provider Demographics
NPI:1912474990
Name:DAVENPORT, KATHERINE MARIAH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARIAH
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:MARIAH
Other - Last Name:CONDREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1615 WATER ST NE APT 22
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0762
Mailing Address - Country:US
Mailing Address - Phone:208-305-8682
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2669
Practice Address - Country:US
Practice Address - Phone:208-305-8681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2987103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist