1639168297 NPI number — MRS. GLENDA L DAVENPORT LCSW

Table of content: MRS. GLENDA L DAVENPORT LCSW (NPI 1639168297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639168297 NPI number — MRS. GLENDA L DAVENPORT LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVENPORT
Provider First Name:
GLENDA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639168297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1996
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TARPON SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34688-1996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-560-8225
Provider Business Mailing Address Fax Number:
727-942-0252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 ATHENS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TARPON SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34689-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-560-8225
Provider Business Practice Location Address Fax Number:
727-942-0252
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW3538 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110337 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SW3538 . This is a "LCSW" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0005848678 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 104602 . This is a "VALUE OPTIONS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6223259 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 001006700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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