Healthcare Provider Details

I. General information

NPI: 1366177826
Provider Name (Legal Business Name): AARON DAVENPORT LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 228-213-5888
  • Fax: 228-705-1952
Mailing address:
  • Phone: 601-705-1901
  • Fax: 601-705-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM10158
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: