Healthcare Provider Details

I. General information

NPI: 1467870048
Provider Name (Legal Business Name): ELISE LOUISE DAVENPORT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 SW COLUMBIA ST SUITE 6210
BEND OR
97702-1099
US

IV. Provider business mailing address

600 SW COLUMBIA ST SUITE 6210
BEND OR
97702-1099
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-3005
  • Fax: 541-383-1883
Mailing address:
  • Phone: 541-383-3005
  • Fax: 541-383-1883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberL6685
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: