Healthcare Provider Details

I. General information

NPI: 1932539350
Provider Name (Legal Business Name): KATHY DAVENPORT-CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2013
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 TOULINE ST
NATCHITOCHES LA
71457
US

IV. Provider business mailing address

PO BOX 29372
SHREVEPORT LA
71149-9372
US

V. Phone/Fax

Practice location:
  • Phone: 318-379-4751
  • Fax: 318-300-3772
Mailing address:
  • Phone: 318-670-8898
  • Fax: 318-476-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number8558
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: