Basic Information
| Provider Information | |||||||||
| NPI: | 1760447585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 CARL VINSON PARKWAY | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789222365 | ||||||||
| FaxNumber: | 4789221778 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 CARL VINSON PARKWAY | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789222365 | ||||||||
| FaxNumber: | 4789221778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 08/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1969 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 572913 | 01 | BCBS | OTHER | 000693448A | 05 | GA | MEDICAID |