Provider Demographics
NPI:1932539350
Name:DAVENPORT-CLARK, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:DAVENPORT-CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29372
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71149-9372
Mailing Address - Country:US
Mailing Address - Phone:318-670-8898
Mailing Address - Fax:318-476-2206
Practice Address - Street 1:118 TOULINE ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457
Practice Address - Country:US
Practice Address - Phone:318-379-4751
Practice Address - Fax:318-300-3772
Is Sole Proprietor?:No
Enumeration Date:2013-11-21
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA85581041S0200X
171M00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool