Basic Information
| Provider Information | |||||||||
| NPI: | 1851663256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 CAMELOT DR | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549358049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209078201 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 W SPRINGFIELD AVE STE 211 | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176216180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2012 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.