Healthcare Provider Details

I. General information

NPI: 1093145674
Provider Name (Legal Business Name): MS. TAMY DAVENPORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EAST 12TH STREET
ADA OK
74820
US

IV. Provider business mailing address

2609 OAKHURST DR APT. B
ADA OK
74820-4673
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-2690
  • Fax:
Mailing address:
  • Phone: 580-332-8285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: