Healthcare Provider Details

I. General information

NPI: 1255578191
Provider Name (Legal Business Name): DAVENPORT DIAGNOSTIC AND TREATMENT CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14275 MIDWAY RD SUITE 220
ADDISON TX
75001-3614
US

IV. Provider business mailing address

14275 MIDWAY RD SUITE 220
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 972-850-0720
  • Fax:
Mailing address:
  • Phone: 972-850-0720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number32578
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number32698
License Number StateTX

VIII. Authorized Official

Name: DR. KIMBERLY C JOHNSON
Title or Position: PSYCOLOGIST
Credential: PSYD
Phone: 972-850-0720