Provider Demographics
NPI:1982324315
Name:DAVENPORT-DESSUS, DESIREE MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:MARIE
Last Name:DAVENPORT-DESSUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DMD WELLNESS LLC
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LLC
Mailing Address - Street 1:9104 BOWFIELD DR STE B
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-6289
Mailing Address - Country:US
Mailing Address - Phone:254-688-0460
Mailing Address - Fax:
Practice Address - Street 1:101 W FM 2410 RD STE C
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1806
Practice Address - Country:US
Practice Address - Phone:254-519-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT134278225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty