Healthcare Provider Details

I. General information

NPI: 1285616912
Provider Name (Legal Business Name): LAURA DAVENPORT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 BARBER CREEK DR STE 213 STE.213
WATKINSVILLE GA
30677-5984
US

IV. Provider business mailing address

PO BOX 1558
WATKINSVILLE GA
30677-0031
US

V. Phone/Fax

Practice location:
  • Phone: 706-548-9545
  • Fax: 706-548-9976
Mailing address:
  • Phone: 706-548-9545
  • Fax: 706-548-9976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC003222
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: