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General NPI Number Information
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NPI Number | 1811675093
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Entity Type | Individual
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Provider Name | CRYSTAL ANGELINA DAVENPORT ACSW
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Gender | Female
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Dates
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Enumeration Date | 07/07/2023
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Last Update Date | 07/07/2023
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Provider Practice Location Address
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Address Line | 1212 N CALIFORNIA ST
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City | STOCKTON
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State | CA
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Zip | 95202-1552
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Country | US
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Telephone | 209-640-9128
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Fax |
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Provider Business Mailing Address
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Address Line | 102 S SAN JOAQUIN ST # 1
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City | STOCKTON
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State | CA
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Zip | 95202-3213
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Country | US
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Telephone | 209-468-2779
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | ASW93101
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License Number State | CA
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