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NPI Code Detail

MEDICARE: JUSTUS DAVENPORT

MEDICARE: JUSTUS DAVENPORT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1053704775
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUSTUS DAVENPORT
Provider Business Mailing Address
First Line : 18040 NE 10TH ST
Second Line :
City : HARRAH
State : OK
Zip : 73045-8115
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 6501 BROADWAY EXT
Second Line : SUITE 180
City : OKLAHOMA CITY
State : OK
Zip : 73116-8239
Country : US
Telephone Number : 405-607-4041
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/05/2015
Last Update Date : 03/05/2015

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Directions to “ JUSTUS DAVENPORT ” Practice Location

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